Claim Sheet

ADJUSTER

Adjuster Name:
Company:
Telephone: Email:
Cell Phone: Claim #:

CUSTOMER

Name:
Address:
Home Phone: Business Phone:
Cell Phone: Email:
Date of Loss: Deductible:

APPRAISALS

 Supplied by Customer

SCHEDULE OF LOSS

Description of Loses Where & When Purchased Original Cost Depreciation Amount Amount Claimed Scheduled Y/N
1
2
3
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5
6
7
8
9
10
11
12

E-mail Address: (Required for Reply)

Date:

Comments: