Network Affiliate

Company Info
Company*
Primary Affiliate Name*
First Last
Primary Affiliate Email*
Primary Affiliate Phone Number*
Insured Info:
Insured Name
First Last
Insured Mobile Phone
Hidden
Alternate Phone
Insured Email Address
Claim Info:
Claim Number
Hidden
Insurance Company*
Hidden
Adjuster Name
First Last
Hidden
Adjuster Phone
Hidden
Adjuster Email Address
Claim Address*
Street Address Address Line 2 City State / Province / Region ZIP Code
Hidden
Date of Loss
MM slash DD slash YYYY
Hidden
Year Home Was Built
Hidden
Claim Specific Email Address
Hidden
Date of Adjuster Meeting (if known)
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, Max. file size: 32 MB.
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.
Email
This field is for validation purposes and should be left unchanged.

Company Info