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Carrier*

Type insured last name

Claim Number*

Type insured last name

Insured Last Name*

Address*

Address1

Address 2

City

State

Zip

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Service Type*

LADDER ASSIST - Adjuster and Technician meet on site at specified time to perform inspection.

DIRECT INSPECTION - No Adjuster present, Hancock sets appointment with Insured and provides inspection information within 48 hrs. ** Insured contact information required**

TARP REMOVE & RESET - Technician removes and resets existing tarp to complete inspection.

EMERGENCY TARP - Technician installs emergency tarp, Hancock sets appointment with insured and installs within 48hrs ** Insured information required **

LADDER ASSIST WITH REPORT - Adjuster and Technician meet on site at specified time to perform inspection. Technician provides written report to adjuster within 48hrs of inspection. Additional upcharge does apply.

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CATASTROPHE EVENT*

Is this claim due to a catastrophe weather event?

Yes

No

Unknown

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RE-INSPECT

Is this claim a re-inspect?

Yes

No

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ADJUSTER CONTACT INFORMATION:

I am NOT an independent adjuster (Don't include billing information)

Type Adjuster email

Email*

Type Adjuster Phone

Phone*

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BILLING CONTACT INFORMATION

I am an independent adjuster (Kindly fill out all information)

Type billing contact email

Email*

Type billing contact form

Phone*

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