Advanced Claims Concepts, Inc.
Property Loss

  • Please provide as much information about the claim as possible
  • Required fields are marked by the * symbol and have a yellow background.
  • If you do not have the information for a required field, please enter "unknown"
  • Claim Details and Assignment Type
    * DOL(mm/dd/yyyy)
    * Claim/file #
    Policy #
    CAT Code 
    Type of Property Involved
    Residential Commercial Industrial
    * Description of Loss/Peril 
    * General Assignment Instructions 
    Client Information/Reporting Address
    * Client Company Name
    * First Name
    * Last Name
    Mailing Address
    Building/Suite
    City
    State
    Zip
    * Phone #
    Fax #
    * E-Mail
    Insured Name and Contact Information:
    * Insured First Name
    Middle
    * Last Name
    Company Name
    Address 1
    Address 2
    City
    * State
    Zip
    * Phone #
    Other Phone #
    Fax #
    Policy Information and Coverage Details
     Limit Deductible Coinsurance Forms
    Coverage A
    Coverage B
    Coverage C
    Coverage D
    Other
    Other Information Concerning Coverage
    Instructions/Other Insured Information
    Agent Information
    Agent First Name
    Middle
    Last Name
    Agency/Broker Company Name
    Address 1
    Address 2
    City
    State
    Zip
    Phone #
    Other Phone #
    Fax #
    Instructions/Other Information Regarding The Agent
    Information On Other Parties
    Please use the following section for identifying additional parties to the loss, such as eye-witnesses, police officers, attorneys, etc. (Not Required).
    Additional Party #1 Claimant Witness Other
    First Name
    Middle
    Last
    Company
    Address1
    Address2
    City
    State
    Zip
    Phone
    Other Phone
    Fax
    Additional Information/Special Instructions
    * Confirm Assignment Receipt
    E-mail Phone By 1st Report
    * Report Within
    1 - 3 Days 3 - 7 Days 7 - 15 Days 15 - 30 Days
    Final Comments

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