Accuval Group LLC New Client Intake Form

Policyholder Information

First Name

Last Name

Phone

Loss Address

Enter the location of the property where the loss occurred.

Asset Type

Street Address

City

State

Zip Code

Policy Information

Insurance Provider Name

Policy Number

Policy Type

Claim Information / Details

Claim Number

Loss Date

Approximate Time Of Loss

Cause of Loss

Loss Description

Date Claim Was Filed

Claim Representative Information

Insurance Contact First Name

Insurance Contact Last Name

Insurance Contact Phone

Insurance Contact Email

Chosen Contractor Contact Information (If Applicable)

If you have a chosen contractor please enter their contact information here. NOTE: We will not communicate with them about the details of your claim unless you specifically request us to do so.

Contractor

Contractor Contact First Name

Contractor Last Name

Contractor Phone

Contractor Email

Contractor Role

Property Details

How many stories is the tallest affected building on the property??

Damage to any detached structures on the property?

Are you aware of any prior claims related to this property?

Any Additional Information You Would Like Us to Know

Submitter Message

Add Files

Upload any documents that are relevant to this claim. Files like a copy of the insurance policy help us expedite the process.

Click to Upload File Here Max file size 50MB. (For all files total) Please be patient with uploads.

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