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Submit Report

1Assignment Details

2Coverage and Reserves

3Risk Assessment

4Investigation

5Documents and Recommendations

Adjuster Information

Name *

E-mail *

Report Information

Claim ID *

MCS File ID *

Insured Name *

Report Number *

Claim Summary

Add information as listed in the policy and Notice of Loss

Summary of Coverage N/A

Submitted With First Report

Policy # *

Policy Start Date *

Policy End Date *

Loss Type *

Loss Date *

Loss Location *

Address Line 1

Address Line 2

City

State

Zip Code

Multiple Locations

Choice 1

Additional Loss Locations

Coverage Limits per Declarations

Add coverage limits applicable to the claim, as listed in the policy

Coverage Limits N/A

Submitted With First Report

Coverage Line (1) *

Amount of Limit *

Coinsurance % *

Settlement *

Add New Line

Choice 1

Coverage Line (2)

Amount of Limit

Coinsurance %

Settlement

Add New Line

Choice 1

Coverage Line (3)

Amount of Limit

Coinsurance %

Settlement

Add New Line

Choice 1

Coverage Line (4)

Amount of Limit

Coinsurance %

Settlement

Add New Line

Choice 1

Coverage Line (5)

Amount of Limit

Coinsurance %

Settlement

Add New Line

Choice 1

Coverage Line (6)

Amount of Limit

Coinsurance %

Settlement

Add New Line

Choice 1

Additional Lines

Deductible

Change applicable deductible provided in previous report

Deductible Breakdown *

Mortgagee

Change mortgagee provided in previous report

Mortgagee Information *

Applying Policy Forms

Change policy forms provided in previous report

Applying Policy Forms *

Suggested Reserves

Document reserves for each coverage line

Reserves N/A

No Reserves Changes From Previous Report

Coverage Line (1) *

Reserve Amount *

Add New Line

Choice 1

Coverage Line (2)

Reserve Amount

Add New Line

Choice 1

Coverage Line (3)

Reserve Amount

Add New Line

Choice 1

Coverage Line (4)

Reserve Amount

Add New Line

Choice 1

Coverage Line (5)

Reserve Amount

Add New Line

Choice 1

Coverage Line (6)

Reserve Amount

Add New Line

Choice 1

Additional Lines

Assignment

Claim Assigned On *

Insured Contacted On *

Inspection Completed On *

Assignment Details *

Risk Description

Risk Description N/A

No changes since previous report, exclude section

Risk Description *

Protective Safeguards

Protective Safeguards N/A

No changes since previous report, exclude section

Protective Safeguards *

Insurance to Value

ITV N/A

No changes since previous report, exclude section

Insurance to Value *

Cause and Origin of Loss

C&O N/A

No changes since previous report, exclude section

Cause and Origin of Loss *

Investigation

Investigation *

Subrogation

Subrogation N/A

No changes since previous report, exclude section

Subrogation *

Salvage

Salvage N/A

No changes since previous report, exclude section

Salvage *

Supporting Files

Enclosures *

Statement of Loss
Estimate
Valuation
Photos
Proof of Loss
ESX File
Other
No Enclosures

List Other Enclosures

How many files would you like to upload?

File Upload

File Upload

File Upload

File Upload

File Upload

File Upload

File Upload

File Upload

File Upload

Recommendations and Remarks

Recommendations and Remarks *

Further Activity

Further Activity *

Certification

I certify, based on information and belief formed after reasonable inquiry, the statements and information contained in these documents are true, accurate and complete. *

First

Last

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Questions? Comments?

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