Network Partners

Company Info
Company*
Primary Partner Name*
First Last
Primary Partner Email*
Primary Partner Phone Number*
Insured Info:
Insured Name
First Last
Insured Mobile Phone
Alternate Phone
Insured Email Address
Claim Info:
Claim Number
Insurance Company*
Adjuster Name
First Last
Adjuster Phone
Adjuster Email Address
Claim Address
Street Address Address Line 2 City State / Province / Region ZIP Code
Date of Loss
Date Format: MM slash DD slash YYYY
Year Home Was Built
Claim Specific Email Address
Date of Adjuster Meeting (if known)
Date Format: MM slash DD slash YYYY
Attach Claim Information
Please upload your claim document or photos.
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png.
Job Description
Please provide AccuWin with a brief description of the claim. Thank you.
Terms and Conditions*
You can view the Terms and Conditions PDF here.
- I Agree to the Terms and Conditions.
Name
This field is for validation purposes and should be left unchanged.

Company Info