Claim Submission – 5th Element Adjusting

1 Claimant

2 Loss

3 Insurance

4 Mortgage

5 Review

File UUID
Primary Contact
Name*
first_name middle_initial last_name
Is this contact a policyholder?
Email*
Phone*
Phone Type*
Mailing Address*
street line_2 city state zip
Secondary Contact
Name
Prefix First Middle Last
Is this contact a policyholder?
Email
Phone
Phone Type*
Secondary Contact address same as Primary Contact?
Mailing Address
street line_2 city state zip

Claim Nickname*
Property Type
Description of Property
Loss address same as contact mailing?
Property Address*
Street Address Address Line 2 City State ZIP Code
Reason for Loss*
Date of Loss*
Date Format: MM slash DD slash YYYY
Cause of Loss/Peril
Loss Attributes
- Is the property habitable?
- Is this a FEMA claim?
- Is there a state of emergency?
Description of Loss

Insurance Carrier*
Insurance Carrier Other*
Policy Number
Claim Number

Mortgage Company*
Mortgage Company Other*
Account Number
Loan Number

Additional Notes
Relevant Attachments
Drop files here or
Terms of Service*
- I agree to the Terms of Service

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