Research & Replacement

Adjuster Email

Adjuster

Insurance Company

Address

Zip

State

City

Phone #

Ext.

Fax #

^{(Check all that apply)}

Type of Loss:

Policy Type:

Payment Tracker _{(Additional Fee)}

Audit Report _{(Additional Fee)}

Obtain Signed Authorization with Replacement

Okay to Contact Insured?

Replacement Approval _{(I authorize Research & Replacement Group to replace
the merchandise requested by our insured.)}

Deductible of $

^{will apply to the item(s) listed.
Deductible will be taken from other items.}

Deductible will be taken from other items.

Special Remarks or Comments:

Policy Holder Email

Policy Holder

Ins. Address

Ins. Zip

Ins. State

Ins. City

Home #

Work# (Mr., Mrs., or Ms.)

Ext

Contact (Mr., Mrs., or Ms.)

^{(Check all that apply)}

Date of Loss:

Date of Loss

Property Limits $

Advance Payments $

Jewelry Scheduled

Appraisal

Jewelry Unscheduled

Per Item $

Limit Total $

Submit a Claim

Attachments

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