Stutman New Loss Report

Please complete the form below:

Referring Insurer
Adjuster's First Name	*
Adjuster's Last Name	*
Adjuster's Email Address	*
Adjuster's Phone Number
Independent Adjuster's First Name
Independent Adjuster's Last Name
Independent Adjuster's Email Address
Independent Adjuster's Phone #
Type of Loss		Fire Water Collapse Explosion Theft Vandalism Other
Date of Loss
Loss Amount
Insured
Loss Location
Claim Number
Insured Contact Name
Insured Contact Number
Cause & Origin Expert Retained?		Yes No
Name of Retained Expert
If applicable, are we authorized to retain a Cause & Origin Expert?		Yes No
Loss Details		Please be SPECIFIC.