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New Assignment for Fort Orange Claim Service (FOCUS)
Your Contact Information
First Name
Last Name
Company
Address (Line 1)
(Line 2)
City
State	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
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Phone:
eMail:
New Assignment Information
Your Claim #:
Assignment Instructions: Characters left:
Insured's Information
Policy #:
Phone #:
Alternate Phone #:
Company:
First Name:
Last Name:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Mortgagee:
Loss Location
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Claimant Information (if applicable)
First Name:
Last Name:
Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Agent Information Show | Hide
First Name:
Last Name:
Company:
Office Phone:
Cell Phone:
Street Address:
Address 2:
City:
State:	AAABAEAKALAPARAZBCCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMBMDMEMIMNMOMSMTNBNCNDNENFNHNJNMNSNTNUNVNYOHOKONORPAPEPRQCRISCSDSKTNTXUTVAVTWAWIWVWYYT
Zip:
Country:
Loss Information
Date of Loss:
Type of Loss:	Animal damaged buildingAppliance LeakageAppraisal/Arbitration RequestAsbestosAuto AppraisalAuto Bodily InjuryAuto Property DamageBodily InjuryBoiler FailureC.G.L. - B. I. C.G.L. - P. D. CargoCollapseCollisionEarth MovementEquipment BreakdownFatality FireFloodFrozen PipesFurnace FailureGlass BreakageGround Water SeepageHail DamageHeat exposure Melted SidingHeavy Equipment AppraisalHot Water Tank LeakIce DamIce/SnowInsect/pest damageLightningLimited/task assignmentMoldMysterious DisappearanceOil LeakagePollution - landPower shut downPower surge/Electrical surgeProfessional LiabilityRoof LeakRot/DeteriorationSewer Back upSinkhole CollapseSlip and FallSmokeSmoke- Puff BackSubrogationSump Pump FailureTenant AbuseTheftTornadoTree on propertyVandalismVehicle struck insured bldgWater back upWater pipe leakWindbasement water seepageCOVID 19Riot & Civil CommotionRiot and Resultant FirePlumbing LeakPipe BurstGas LeakHurricaneOil Tank LeakCYBER SECURITYAccidental Water Discharge BIO HAZARD - BODY CLEAN UPDESK ADJUSTMENTAUTO LIABILITY PROPERTY DAMAGE
Unit:	Arbitration RequestAuto AppraisalAuto - B.I. (Bodily Injury)Auto DamageAuto LiabilityAuto Property DamageBoiler & MachineryBuilders RiskC.G.L. B.I.C.G.L. P.D.CargoCasualty Limited AssignmentCommercial General LiabilityCommercial PropertyEmployee DishonestyEnvironmental LiabilityInland MarineLiquor LiabilityNo FaultPersonal Lines - LiabilityProperty Appraisal GoldProperty ScheduleResidential PropertySubrogationSprinklerTheft Workers Comp
Type of Adjustment:	Limited Full
Loss Description: Characters left:
VIN #:
Deductible:
Wind Deductible:
Coverage ABuildingContentsLoss Of Earnings
Coverage BBuildingContentsLoss Of Earnings
Coverage CBuildingContentsLoss Of Earnings
Coverage DBuildingContentsLoss Of Earnings
Endorsements:
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