Insurance Claims Submission | Insurance Adjuster

Fill out the relevant areas below to submit a claim. One of our associates will contact you within 24 hours.

Insurance Carrier or Referring Company
Name:
Address1:
Address2:
City/State/Zip:
Referring Adjuster or Company Contact
Name:
E-mail:
Phone:
Would you rather receive the report via E-mail or Regular Mail
E-mail:
Regular Mail

Your Claim or File Number: #

Insured Name and Address
Name:
Address1:
Address2:
City/State/Zip:
Daytime Phone:

Loss Location (if different from above)
Contact:
Address1:
Address2:
City/State/Zip:

Coverages
Dwelling/Building:
Loss of Use/ALE:
Contents/UPP:
Deductible/Co-Insurance:
Liability per Occurrence Limit:
Liability per Aggregate Limit:
Per Claim Limit:
Aggregate Erosion:
Applicable Forms

Special instructions, requirements, and any other specifics related to this assignment to help ensure that we meet your needs:

Our services also include:
• Photographs
• Estimates
• Diagrams
• Agreed Figures for Each Service, When Requested

Adjuster Certifications
• AMIM: Associate in Marine Insurance Management
• ARM: Associate in Risk Management
• AIS: Associate in Insurance Services
• CRIS: Construction Risk and Insurance Specialist
• CPCU: Chartered Property Casualty Underwriter

Please contact us with any questions or comments regarding our services:
Phone: (866) 861-0157
Emergency Number: (803) 372-9317
E-mail: info@cubitgroupllc.com