The National Association of Independent Insurance Adjusters

Property Claim Submission

Submit claim to the following NAIIA Member:

Allen Dahle & Company, Inc.

65 W Red Oak Lane, White Plains, NY 10604

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Claim Details and Assignment Type

* DOL(mm/dd/yyyy)

/ /

* Claim / File #

* Policy #

CAT Code

Type of Property Involved

Residential

Commercial

Industrial

* Description of Loss/Peril

* General Assignment Instructions

Client Information/Reporting Address

* Client Company Name

* First Name

* Last Name

* Mailing Address

Building/Suite

* City

* State

* Zip

* E-Mail Address

* Phone #

Fax #

Insured Name and Contact Information:

* Insured First Name

Middle

* Last Name

Company Name

Address 1

Address 2

City

State

Zip

* Phone #

Other Phone #

Fax #

Policy Information and Coverage Details

	Limit	Deductible	Coinsurance	Forms
Coverage A
Coverage B
Coverage C
Coverage D
Other

Other Information Concerning Coverage

Instructions/Other Insured Information

Information On Other Parties - Claimant/Witness

Additional Party #1

CLAIMANT

WITNESS

First Name

Middle

Last Name

Company Name

Address 1

Address 2

City

State

Zip

Phone #

Fax #

E-Mail

Additional Information / Special Instructions

Agent Information

Agent First Name

Middle

Last Name

Agency/Broker Company Name

Address 1

Address 2

City

State

Zip

Phone #

Fax #

E-Mail

Instructions/Other Information Regarding The Agent

Additional Information

* Confirm Assignment Receipt

E-mail

Phone

By 1st Report

* Report Within

1 - 3 Days

3 - 7 Days

7 - 15 Days

15 - 30 Days

Final Comments

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