Allied Salvors inc.

Loss Reporting

To submit a Loss Report please fill out this form with as much information as possible in order to ensure a quick response. An Allied Salvors representative will contact you in a timely fashion to handle any immediate concerns and discuss next steps in completing your claim.

Insured Contact Information

Insured:

Address 1:

Address 2:

Zip:

Phone Number:
(xxx-xxx-xxxx)

Cell Number:
(xxx-xxx-xxxx)

Contact Name:

City:

State:

E-mail:

Fax Number:
(xxx-xxx-xxxx)

Alternate Contact Information

Alt Contact Name:

Alt Phone Number:
(xxx-xxx-xxxx)

Alt E-mail:

Alt Cell Number:
(xxx-xxx-xxxx)

Adjuster Contact Information

Please check one:

Independent Adjuster Insurance Company Adjuster

Adjuster Name:

Company:

Address 1:

Address 2:

Phone Number:
(xxx-xxx-xxxx)

Cell Number:
(xxx-xxx-xxxx)

Title:

City:

State:

Zip:

E-mail:

Fax Number:
(xxx-xxx-xxxx)

Loss Information

Insurance Company:

Date of Loss:

Type of Stock:

Claim #:

Loss Type
Fire, Flood, etc:

Value of Stock:

Description
of Stock:

Policy Limits:

Co-Insurance:
(If Applicable)

Public Adjuster (If Applicable)

Contact Name:

Phone Number:
(xxx-xxx-xxxx)

Cell Number:
(xxx-xxx-xxxx)

Company Name:

Fax Number:
(xxx-xxx-xxxx)

E-mail:

Special Instructions

Separate Damages

Inventory Damages Only

Inventory Damaged and Undamaged Post Loss

Dispose of Salvage

Inventory Reconstruction

Other: