To Submit a Claim, please fill out the form completely and a FRSTeam representative will contact you.

Name of Person Reporting Claim:
Phone Number

Type of Loss
Insured Name(s)

Claim/Reference Number:

Loss Site Address
City
State
Zip Code

Insured Contact Numbers Home Phone Number:
Work Phone Number
Cell Phone Number:
Email:

Authorized Items to pick up in affected areas Clothing
Bedding
Window Treatments
Specialty Clean Items:
(Foot wear, Plush Toys, Accessories — Please List)
On-site Special Instructions Hold For Bill Approval Yes
No

Bill To Information: Company Name Address City State Zip Code Phone Fax Adjuster/Contact Email

Attention

There were some problems with the information you have submitted. Listed below are the fields that need attention.