Research & Replacement

Adjuster Email

Adjuster

Insurance Company

Branch/District

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

Policy Address

Zip

State

City

Phone 1

Phone 2

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