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New Loss Form

If you’ve just suffered a merchandise, equipment or commodities loss as the result of natural disaster, storm, fire, flood, theft, accident or some other unforeseen event, please fill out the form below to assist us in assessing your immediate needs. One of our salvage experts will contact you as soon as possible to discuss your case and commence arrangements for the needed services.

Please fill out your information below to receive the requested information

* Indicates required field.

   
Consigned Date (xx/xx/xxxx)
Adjuster or Claim Representative
Contact Name* :
Company :
Address 1 :
Address 2 :
City :
State :
Zip Code :
Phone Number : (xxx-xxx-xxxx)
Fax Number : (xxx-xxx-xxxx)
Cell Number : (xxx-xxx-xxxx)
Email :
Alternate Number : (xxx-xxx-xxxx)
Adjuster File Number :
   
Public Adjuster (if applicable)  
Contact Name :
Company :
Phone Number : (xxx-xxx-xxxx)
Fax Number : (xxx-xxx-xxxx)
Cell Number : (xxx-xxx-xxxx)
   
Loss Information   
Date of Loss : (xx/xx/xxxx)
Nature of Loss :
Character of Goods :
Estimated Value of Stock :
  Cost     Retail
   
Insured's Information    
Contact Name :
Company :
dba :
Address 1 :
Address 2 :
City :
State :
Zip Code :
Phone Number : (xxx-xxx-xxxx)
Fax Number : (xxx-xxx-xxxx)
Cell Number : (xxx-xxx-xxxx)
Additional Information :

Companies Interested    
Insurance Company :
Policy Number :
Claim Number :
Tracking Number : (if applicable)
Amount of Insurance :
   
SPECIAL NOTES OR INSTRUCTIONS :
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