New HVAC Claim Please enable JavaScript in your browser to complete this form.1Adjuster Info2Insured Info3Claim Info & AttachmentsName *FirstLastEmail *Phone *Company Name *Are you an Independent Adjuster?NoYesCarrier Account *Carrier Account POC Information *Please provide name and contact information for carrier adjuster.AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextInsured Name *FirstLastProperty Type *ResidentialCommercialLoss LocationInsured AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Do you want to add a Point of Contact?YesNoPOC Name *POC Phone *POC Details * Add Media Visual Text NextLayoutClaim Number *Type of Loss *Foreign Object ImpactFreezing ConditionsHailHigh Voltage SurgeImproper InstallationLightningMechanical BreakdownSmoke / FireTheft / VandalismUnknownWaterWear & TearWindDate of Loss *Carrier Claim Specific Email *Did the insured report any other collateral damage as part of this claim?YesNoPlease enter other reported collateral damageDesktop Review Only?Yes (Desktop Review Only)No (Onsite Inspection)Please confirm by selecting Desktop Review Only that a Cause of Loss determination and an opinion regarding the proposed Scope of Repairs will not be provided in our findings. An on-site assessment of the claimed equipment is necessary to provide this information. LayoutLoss Description *Client Special Instruction *Special Instructions for SchedulingDo No Contact the InsuredInsured is Spanish SpeakingInsured is Tax ExemptMeet Adjuster OnsiteMultiple Properties (Commercial Claim)Schedule with AttorneySchedule with ContractorSchedule with PAPreviousSubmit Claim
