Referral Source Claim Submission Form

Please submit your contact information (person submitting the form)

Your Company Name*

First Name*

Last Name*

Email Address*

Phone Number

Is the Claim a Commercial or Residential Property?

Commercial

Residential

Claim Property Information - The property where the loss occurred

Company Name | Named Insured

Insured Authorized Signor

First Name*

Last Name*

Email Address*

Phone Number

Property and Policy Claim Information

Property Address*

Street Address Suite/Apartment Number City State Zip Code

What is the Loss Event / Case Type?*

What is the name of the storm that caused the loss?

Date of Loss (Incident Date)*

Please provide your best estimate if you are unsure of the exact date

Insurance Company (at Time of Loss)

Insurance Policy Number:

Has a claim been filed for this loss event?*

Yes

Date the Claim Was Filed

Please provide your best estimate if you are unsure of the exact date

Insurance Claim Number

File Sharing Link

If a file sharing link has already been established for this claim, please enter it here.

Is there an additional referral source associated with this claim?

Yes

Please give the Company Name for the additional referral source here.

Please select the business category for the additional referral source.

Please share any additional information that will help us understand and process your referred claim.

Does Pate Smith want to discuss this claim prior to signing?

Yes