Mission Statement:

We are committed to providing our clients with superior fire and explosion investigation services,  to assist our customers in making the most informed decisions.

Starr Fire and Explosion Investigations Intake Form

Fields with asterisk (*) are required.


Assignment Submitted By

Company:

Your Name:

*

Address:

City:

State:

Zip Code:

Policy Number:

Claim Number:

Telephone:

*

Fax:

E-mail:

Confirm Assignment By:


Bill To (complete if different from above)

Company:

Attention:

Address:

City:

State:

Zip Code:

Telephone:

Fax:

E-mail:


Location of Loss

Address:

City:

State:

Zip Code:

Date of Loss:

Time of Loss:


Insured / Subject

Name:

Telephone:

Contact Person:

Telephone:

Include address if different from location of loss

Address:

City:

State:

Zip Code:


Additional Loss Information

Type of Loss:

Type of Property:

Occupancy:

Insurance Coverage:

 

Building:

$

Contents:

$

Other:

$

Vehicle Information (if applicable)

Manufacturer:

Year:

Vehicle Location:

Model:

VIN:

Color:

Adjuster Name:

Adjuster Telephone:

Civil Authority Investigating:

Agency:

Contact:

Telephone:


Instructions or Comments

 

 

 


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