Report a Loss - Intake Form

National Group - Your One Call to Recovery

Please click the selection headings expand the form. Required fields are denoted by a *.

Private National Group Info

Office Use Only

NIS File No:

NCS File No::

NNL File No:

CPA File No:

Date Taken:

Time Taken:

Taken By:

Marketer:

Date Assigned:

Time Assigned:

Assigned By:

Assigned To:

Inspection By:

Report By:

Report Type (Oral, Letter, etc):

Client Contact Information

Company:

Contact Name: *

Contact Mobile #:

Address: *

Office Phone #: *

Office Fax #:

E-mail Address:

Client's Client Information

Company/Broker/Agent:

Client Contact Name:

Client Contact Mobile #:

Client Address:

Client Office Phone #:

Client Office Fax #:

Client E-mail Address:

Billing Information

Fee Limit (if any):

Billing Contact Name:

Billing Address:

Billing Office Phone #:

Billing Office Fax #:

Billing E-mail Address:

Send Report To:

Client's Attorney Information

Firm Name:

Attorney Contact Name:

Attorney Address:

Attorney Office Phone #:

Attorney Office Fax #:

Attorney E-mail Address:

Attorney File #:

Attorney Case Caption:

Claim Information

Client Claim #:

Client File #:

Client Policy #:

Client's Client Claim #:

Client's Client File #:

Client's Client Policy #:

Serviced Required: *

General Description:

Loss Information

Claim Type:

Date of Loss: *

Loss Location Address: *

Due Date:

Insured Contact Information

Insured Name: *

Insured Contact: *

Insured Contact Mobile #:

Insured Address:

Insured Office Phone #: *

Insured Office Fax #:

Insured Mobile #:

Insured E-mail Address:

Insured P.A./Attorney

Insured P.A./ Attorney Name:

Insured P.A./ Attorney Contact:

Insured P.A./ Attorney Contact Mobile #:

Insured P.A./ Attorney Address:

Insured P.A./ Attorney Office Phone #:

Insured P.A./ Attorney Office Fax #:

Insured P.A./ Attorney Mobile #:

Insured P.A./ Attorney Email:

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Testimonials

"I very much enjoyed our association with National Group during the last four months as you in effect saved our building at WVLT-TV in Knoxville, Tennessee. You and your people are true professionals. You worked with us and around us with a minimum of interruptions. Again, congratulations on a job well done."

Joseph A. Carriere

Vice President of Television, Gray Communications Systems, Inc.

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