Prepared for:

Primary Adjuster's Name

First

Last

Insurance Company

Adjuster/Claim Email

Adjuster's Phone Number

Insured Info:

Insured Name

Policyholder Title

First

Last

Insured Mobile Number

Alternate Phone Number

Insured Email Address

Claim Number

Claim Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Date of Loss

Year Home Was Built

Type of Loss

Site Inspection Date(MM/DD/YYYY)

Site Inspection Time(EST Timezone)

Claim Specific Email Address

Claim Documents

Number of Documents to Upload

Document 1

Document 2

Document 3

Document 4

Document 5

Document 6

Document 7

Document 8

Document 9

Document 10

Claim Description

Please provide AccuWin with a brief description of the claim. Thank you.

Terms and Conditions

You can view the Terms and Conditions PDF here.

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I Agree to the Terms and Conditions.

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