To: Gemcor Claims Specialist       Fax: (800) 432-3282

FROM:

Adjuster (First & Last name):

Insurance Company:

Mailing Address:

Phone:
Ext.

Fax:

Email:

Would you like a confirmation of receipt?

REGARDING:

Your claim number:

Name of Insured:

Insured's Home Phone:

Insured's Work Phone:

Insured's email address:

Insured's Address:

Policy Limit:

Deductible:

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Add Another File

Description of Loss: (and please fax any corresponding appraisal information):

Do we have permission to contact the insured to collect more information?
YesNo

Do we have permission to contact the insured to discuss our services?
YesNo