Loss Evaluation Request

Client & Handler Information Client/Carrier Name *

Claim Handler Name *

Handler Office Address *

Handler City/State/Zip *

Handler Phone *

Extension

Handler Email *

Handler Fax

Insured & Contact Detail Insured *

Claimant *

Defaulter (Fidelity Only)

Contact Name

Contact Position

Contact Phone

Contact Address

Contact City/State/Zip

Enter Coverages, Applicable Forms & Limits

Occurrence Detail Claim Number *

Date of Loss *

Claimed Amount *

Type of Loss *

Start Date

End Date

Description of Loss *

Special Request or Attention Details

Submit Request

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320 Cumberland Street

Lebanon, PA 17042