Commercial Loss Referral Form

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ADJUSTER
Company Name*
Adjuster's Name*
FirstLast
Address*
Street AddressAddress Line 2CityProvincePostal Code
Email*
Phone*
Fax
INSURED
Company Name*
Address
Street AddressAddress Line 2CityProvincePostal Code
Phone
Fax
Contact Name
FirstLast
LEGAL REPRESENTATIVE (if applicable)
Firm Name
Legal Representative's Name
FirstLast
Address
Street AddressAddress Line 2CityProvincePostal Code
Phone
Fax
CLAIM / POLICY INFORMATION
Claim Number*
Policy Number*
Date of Loss*
MM slash DD slash YYYY
Type of Claim*
- Inventory Loss
- Business Interruption
- Extra Expense
- Fidelity / Employee Dishonesty
- Jewellers Block
- Product Liability
- Downtime
- Arson-For-Profit
DOCUMENTATION RECEIVED (Please forward to us)
Please forward to us by fax, mail or attach by using "Upload Documents" button below. You can upload a single ZIP file or upload individual files for each type of document received
Please select all documents that will be forwarded to us
- Proof of Loss
- Supporting Documents
- Insured's Statement
- Policy Wording
- Policy Declarations
Other documention received but not listed above?
Please provide a list of the documents received in the field below:
Upload Documents
Drop files here or
Accepted file types: jpg, jpeg, png, pdf, doc, docx, gif, xls, xlsx, csv, txt, rtf, Max. file size: 64 MB.
COMMENTS
Please add any details or comments in the field below:

Insignia Forensic Group

168 Queen Street S, Suite 218, Mississauga, ON L5M 1K8

Commercial Loss Referral Form

ADJUSTER

INSURED

LEGAL REPRESENTATIVE (if applicable)

CLAIM / POLICY INFORMATION

DOCUMENTATION RECEIVED (Please forward to us)

COMMENTS