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Dynamic Claims Services, Inc.™
Property Loss
Please provide as much information about the claim as possible.
Required fields are marked by the * symbol and must be completed in order to process your request. If required fields are not completed in full, submission of form may take you to an error page. Your information will not be saved and will have to be reentered.
If you do not have the information for a required field, please enter "unknown".
DOL (mm/dd/yyyy)
*
This is a required field and must be in mm/dd/yyyy format.
Claim/File #
*
This is a required field.
Policy #
*
CAT Code
*
Type of Property Involved
*
Residential
Commercial
Industrial
Description of Loss or Peril
*
Please provide us with a detailed description of loss. This is a required field.
General Assignment Instruction
*
Please provide us with detailed instructions of assignment. This is a required field.
Client Information/Reporting Address
Client Company Name
*
Company name is a required field.
Name
*
First
Last
First and last name of contact is required.
Client's Mailing Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
-
-
Must be entered in a xxx-xxx-xxxx format. If this is an international number, please enter details in the General Assignment Instructions field.
Secondary Number
*
-
-
Fax Number
*
-
-
Email
*
Contact e-mail address is a required field.
Insured Name and Contact Information
Insured's Name
*
First
Last
Insured's Company Name
*
Insured's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Insured's Number
*
-
-
Secondary Number
*
-
-
Fax Number
*
-
-
Insured's Email Address
*
Polic
y Information and Coverage Details.
Coverage A
Limit of Coverage A
*
Please enter the limit for Coverage A.
Deductible of Coverage A
*
Please enter the deductible for Coverage A.
Coinsurance of Coverage A
*
Forms of Coverage A
*
Coverage B
Limit of Coverage B
*
Deductible of Coverage B
*
Coinsurance of Coverage B
*
Forms of Coverage B
*
Other Information Concerning Coverage
*
Instructions/Other Insured Information
*
Agent Name and Contact Information
Agent's Name
*
First
Last
Agent's Company Name
*
Agent's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Please enter if 'Other' was selected.
Agent's Number
*
-
-
Secondary Number
*
-
-
Fax Number
*
-
-
Agent's Email
*
Instructions/Other Information Regarding the Agent.
*
Information On Other Parties
Please us 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
Name of Other Party
*
First
Last
Other Party's Company Name
*
Other Party's Address
*
Line 1
Line 2
City
State
Zip Code
Country
Other Party's Number
*
-
-
Secondary Number
*
-
-
Other Party's Email
*
Fax Number
*
-
-
Additional Information/Special Instructions
*
Confirm Assignment Receipt
*
E-mail
Phone
By 1st Report
Please confirm your preference in assignment receipt.
Report Within
*
1-3 Days
3-7 Days
7-15 Days
15-30 Days
Please advise your preference in reporting. This is a required field.
Final Comments
*
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
Upload File
*
Max file size: 20MB
