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Client Info
Claim Info
Description
Details
Review

Client Information

*All Fields Required

Claim Information

Description

Brief Description of Loss (What Happened)

What do you want us to do? (Scope of Work)

Attach Files

Max: 6 files (30 MB total)

Accepted File Types: .jpg, .pdf, .docx, .xlsx

Details

Request a Specific Expert


Discuss budget before starting?

Is this the first time using Envista?


Review

Client Information

Name
{{firstName}} {{lastName}}
Company
{{company}}
Email Address
{{emailAddress}}
Work Address
{{addressLine1}} {{addressLine2}}
{{city}}, {{state}}{{canadianProvince}} {{postalCode}}
{{country}}
Work Phone Number
{{phoneNumber}}
Job Title
{{jobTitle}}
Billing Address
{{billingFirstName}} {{billingLastName}}
{{billingAddressLine1}} {{billingAddressLine2}}
{{billingAddressCity}}, {{billingAddressState}}{{billingCanadianProvince}} {{billingAddressPostalCode}}
{{billingAddressCountry}}

Claim Information

Claim Number
{{claimNumber}}
Date Of Loss
{{dateOfLoss}}
Claim Amount
{{claimAmount}}
Insured's Name
{{insuredsName}}
Insured Contact Name
{{insuredContactFirstName}} {{insuredContactLastName}}
Insured's Phone Number
{{insuredsPhoneNumber}}
Insured's Email Address
{{insuredsEmailAddress}}
Insured's Address
{{insuredsAddressLine1}} {{insuredsAddressLine2}}
{{insuredsCity}}, {{insuredsState}}{{insuredsCanadianProvince}} {{insuredsPostalCode}}
{{insuredsCountry}}
Loss Location
{{lossAddressLine1}} {{lossAddressLine2}}
{{lossAddressCity}}, {{lossAddressState}}{{lossCanadianProvince}} {{lossAddressPostalCode}}
{{lossAddressCountry}}

Description

Description of Loss
{{briefDescriptionOfLoss}}
Scope of Work
{{whatDoYouWantUsToDo}}
Files
    {{attachFilesInfo}}

Details

Requested Expert
{{requestSpecificExpert}}
Discuss Budget Y/N
{{discussBudgetBeforeStarting}}
First Time Using Envista Y/N
{{firstTimeUsingEnvista}}
How did you hear about us?
{{howDidYouHearAboutUs}}
How did you hear about us? (other)
{{howDidYouHearAboutUsOther}}
Client Info
Case Info
Description
Details
Review

Client Information

*All Fields Required

Case Information

Case Information


Do You Want a Sales Person To Contact You?

Is a case being submitted?

Description

Brief Description of Loss (What Happened)

What do you want us to do? (Scope of Work)

Attach Files

Max: 6 files (30 MB total)

Accepted File Types: .jpg, .pdf, .docx, .xlsx

Details

Request a Specific Expert


Discuss budget before starting?

Is this the first time using Envista?

Review

Client Information

Name
{{firstName}} {{lastName}}
Company
{{company}}
Email Address
{{emailAddress}}
Work Address
{{addressLine1}} {{addressLine2}}
{{city}}, {{state}}{{canadianProvince}} {{postalCode}}
{{country}}
Work Phone Number
{{phoneNumber}}
Job Title
{{jobTitle}}
Billing Address
{{billingFirstName}} {{billingLastName}}
{{billingAddressLine1}} {{billingAddressLine2}}
{{billingAddressCity}}, {{billingAddressState}}{{billingAddressCanadianProvince}} {{billingAddressPostalCode}}
{{billingAddressCountry}}

Case Information

Do You Want a Sales Person To Contact You?
{{salesPersonContact}}
Is a case being submitted?
{{submittingACase}}
Parties Involved
{{partiesInvolved}}
Case
{{caseInfo}}
Loss Address
{{lossAddressLine1}} {{lossAddressLine2}}
{{lossAddressCity}}, {{lossAddressState}}{{lossAddressCanadianProvince}} {{lossAddressPostalCode}}
{{lossAddressCountry}}

Description

Description of Loss
{{briefDescriptionOfLoss}}
Scope of Work
{{whatDoYouWantUsToDo}}
Files
    {{attachFilesInfo}}

Details

Requested Expert
{{requestSpecificExpert}}
Discuss Budget Y/N
{{discussBudgetBeforeStarting}}
First Time Using Envista Y/N
{{firstTimeUsingEnvista}}
How did you hear about us?
{{howDidYouHearAboutUs}}
How did you hear about us? (other)
{{howDidYouHearAboutUsOther}}
Client Info
Claim Info
Insurer Info
Description
Details
Review

Client Information

*All Fields Required

Claim Information

Insurer Information

Carrier Information

Carrier 1
Carrier 2
Carrier 3
Carrier 4
Carrier 5
Carrier 6
Carrier 7
Carrier 8
Carrier 9
Carrier 10

Lloyds of London

Description

Brief Description of Loss (What Happened)

What do you want us to do? (Scope of Work)

Attach Files

Max: 6 files (30 MB total)

Accepted File Types: .jpg, .pdf, .docx, .xlsx

Details

Request a Specific Expert


Discuss budget before starting?

Is this the first time using Envista?

Review

Client Information

Name
{{firstName}} {{lastName}}
Company
{{company}}
Email Address
{{emailAddress}}
Work Address
{{address1}} {{insuranceAdjuster_address2}}
{{city}}, {{insuranceAdjuster_state}}{{canadianProvince}} {{postalCode}}
{{country}}
Work Phone Number
{{phoneNumber}}
Job Title
{{jobTitle}}
Billing Address
{{billingFirstName}} {{billingLastName}}
{{billingAddressLine1}} {{billingAddressLine2}}
{{billingAddressCity}}, {{billingState}}{{billingCanadianProvince}} {{billingAddressPostalCode}}
{{billingAddressCountry}}

Claim Information

Claim Number
{{claimNumber}}
{{adjustersFileNumber}}
Date Of Loss
{{dateOfLoss}}
Claim Amount
{{claimAmount}}
Insured's Name
{{insuredsName}}
Insured Contact Name
{{insuredContactFirstName}} {{insuredContactLastName}}
Insured's Phone Number
{{insuredsPhoneNumber}}
Insured's Email Address
{{insuredsEmailAddress}}
Insured's Address
{{insuredsAddressLine1}} {{insuredsAddressLine2}}
{{insuredsCity}}, {{insuredsState}}{{insuredsCanadianProvince}} {{insuredsPostalCode}}
{{insuredsCountry}}
Loss Location
{{lossAddressLine1}} {{lossAddressLine2}}
{{lossAddressCity}}, {{lossAddressState}}{{lossCanadianProvince}} {{lossAddressPostalCode}}
{{lossAddressCountry}}

Insurer Information

Carrier 1
Company
{{insurer1Company}}
Name
{{insurer1FirstName}} {{insurer1LastName}}
Email Address
{{insurer1EmailAddress}}
Work Address of Insurer
{{insurer1AddressLine1}} {{insurer1AddressLine2}}
{{insurer1City}}, {{insurer1State}}{{insurer1CanadianProvince}} {{insurer1PostalCode}}
{{insurer1Country}}
Carrier 2
Company
{{insurer2Company}}
Name
{{insurer2FirstName}} {{insurer2LastName}}
Email Address
{{insurer2EmailAddress}}
Work Address of Insurer
{{insurer2AddressLine1}} {{insurer2AddressLine2}}
{{insurer2City}}, {{insurer2State}}{{insurer2CanadianProvince}} {{insurer2PostalCode}}
{{insurer2Country}}
Carrier 3
Company
{{insurer3Company}}
Name
{{insurer3FirstName}} {{insurer3LastName}}
Email Address
{{insurer3EmailAddress}}
Work Address of Insurer
{{insurer3AddressLine1}} {{insurer3AddressLine2}}
{{insurer3City}}, {{insurer3State}}{{insurer3CanadianProvince}} {{insurer3PostalCode}}
{{insurer3Country}}
Carrier 4
Company
{{insurer4Company}}
Name
{{insurer4FirstName}} {{insurer4LastName}}
Email Address
{{insurer4EmailAddress}}
Work Address of Insurer
{{insurer4AddressLine1}} {{insurer4AddressLine2}}
{{insurer4City}}, {{insurer4State}}{{insurer4CanadianProvince}} {{insurer4PostalCode}}
{{insurer4Country}}
Carrier 5
Company
{{insurer5Company}}
Name
{{insurer5FirstName}} {{insurer5LastName}}
Email Address
{{insurer5EmailAddress}}
Work Address of Insurer
{{insurer5AddressLine1}} {{insurer5AddressLine2}}
{{insurer5City}}, {{insurer5State}}{{insurer5CanadianProvince}} {{insurer5PostalCode}}
{{insurer5Country}}
Carrier 6
Company
{{insurer6Company}}
Name
{{insurer6FirstName}} {{insurer6LastName}}
Email Address
{{insurer6EmailAddress}}
Work Address of Insurer
{{insurer6AddressLine1}} {{insurer6AddressLine2}}
{{insurer6City}}, {{insurer6State}}{{insurer6CanadianProvince}} {{insurer6PostalCode}}
{{insurer6Country}}
Carrier 7
Company
{{insurer7Company}}
Name
{{insurer7FirstName}} {{insurer7LastName}}
Email Address
{{insurer7EmailAddress}}
Work Address of Insurer
{{insurer7AddressLine1}} {{insurer7AddressLine2}}
{{insurer7City}}, {{insurer7State}}{{insurer7CanadianProvince}} {{insurer7PostalCode}}
{{insurer7Country}}
Carrier 8
Company
{{insurer8Company}}
Name
{{insurer8FirstName}} {{insurer8LastName}}
Email Address
{{insurer8EmailAddress}}
Work Address of Insurer
{{insurer8AddressLine1}} {{insurer8AddressLine2}}
{{insurer8City}}, {{insurer8State}}{{insurer8CanadianProvince}} {{insurer8PostalCode}}
{{insurer8Country}}
Carrier 9
Company
{{insurer9Company}}
Name
{{insurer9FirstName}} {{insurer9LastName}}
Email Address
{{insurer9EmailAddress}}
Work Address of Insurer
{{insurer9AddressLine1}} {{insurer9AddressLine2}}
{{insurer9City}}, {{insurer9State}}{{insurer9CanadianProvince}} {{insurer9PostalCode}}
{{insurer9Country}}
Carrier 10
Company
{{insurer10Company}}
Name
{{insurer10FirstName}} {{insurer10LastName}}
Email Address
{{insurer10EmailAddress}}
Work Address of Insurer
{{insurer10AddressLine1}} {{insurer10AddressLine2}}
{{insurer10City}}, {{insurer10State}}{{insurer10CanadianProvince}} {{insurer10PostalCode}}
{{insurer10Country}}
UMR (Unique Market Reference)
{{lloydsUMR}}
UCR (Unique Claim Reference)
{{lloydsUCR}}
OSND (Original Signing Number and Date)
{{lloydsOSND}}
Order (% of responsibility)
{{lloydsOrder}}
Lloyd’s lead (Lead syndicate on the policy)
{{lloydsLeadSyndicate}}
UW contact (Underwriter contact)
{{lloydsUWContact}}

Description

Description of Loss
{{briefDescriptionOfLoss}}
Scope of Work
{{whatDoYouWantUsToDo}}
Files
    {{attachFilesInfo}}

Details

Requested Expert
{{requestSpecificExpert}}
Discuss Budget Y/N
{{discussBudgetBeforeStarting}}
First Time Using Envista Y/N
{{firstTimeUsingEnvista}}
How did you hear about us?
{{howDidYouHearAboutUs}}
How did you hear about us? (other)
{{howDidYouHearAboutUsOther}}
Client Info
Description
Review

Client Information

*All Fields Required

Description

Brief Description of Loss (What Happened)

What do you want us to do? (Scope of Work)

Attach Files

Max: 6 files (30 MB total)

Accepted File Types: .jpg, .pdf, .docx, .xlsx

Review

Client Information

Name
{{firstName}} {{lastName}}
Company
{{company}}
Email Address
{{emailAddress}}
Work Address
{{addressLine1}} {{addressLine2}}
{{city}}, {{state}}{{canadianProvince}} {{postalCode}}
{{country}}
Work Phone Number
{{phoneNumber}}
Job Title
{{jobTitle}}
Billing Address
{{billingFirstName}} {{billingLastName}}
{{billingAddressLine1}} {{billingAddressLine2}}
{{billingAddressCity}}, {{billingAddressState}}{{billingCanadianProvince}} {{billingAddressPostalCode}}
{{billingAddressCountry}}

Description

Description of Loss
{{briefDescriptionOfLoss}}
Scope of Work
{{whatDoYouWantUsToDo}}
Files
    {{attachFilesInfo}}
How did you hear about us?
{{howDidYouHearAboutUs}}
How did you hear about us? (other)
{{howDidYouHearAboutUsOther}}
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