1.877.TECHLOSS
(1.877.832.4567)
fax: 1.847.541.2325

Submit a Loss

Project Initialization Form - *mandatory fields [Download the PDF]
Section 1 - CLIENT INFORMATION
 		Section 2 - INSURED INFORMATION
Company
Contact Name
Address
City
State
Zip Code
Telephone
Fax Number
E-mail*
Company
Contact Name
Address
City
State
Zip Code
Telephone
Fax Number
E-mail
Section 3 - LOSS INFORMATION
Claim Number
Date of Loss
Estimated Claim Amount
Section 4 - WHY DID YOU CHOOSE TECHLOSS? (Please check & specify)
Preferred Vendor Conf./Seminar Print Ad/Web Site Direct Mailer
Specify
Section 5 - INDUSTRY GROUPS
Insurance Legal Government Self-Insured Independent Adjusters
Other
Section 6 - LOSS TYPE: (Please check all that apply)
Lightning Power Surge Fire Smoke Damage Water Damage
Mold Damage Theft OTR/Transportation Residential Property
Commercial Property Commercial / Residential Accidents Terrorist Related Data Losses
Virus Damage Data Deletion
Other
Section 7 - ACTIONS REQUIRED: (Please check all that apply)
ACV: Actual Cash Value
QCP Program
Causation
Data Management Solutions
Coordinate Repairs
Pre-Loss Planning
Lightning Verification
Data Retrieval 		Expert Witness
Reparability
In-House Testing
Restoration
Invoice Review
Salvage
Recertified Replacement Cost
LKQ Verification 		Nationwide On-Site Inspection
Virus Removal
Project Management
Software Recovery
RCV: Replacement Cash Value
Damage Verification
Subrogation
Surge Type: Lightning vs. Utility
Other
Section 8 - PREDOMINANT EQUIPMENT: (Please check all that apply)
Computers/Hard Drives Monitors Printing Equipment Communications
Medical Equipment Intercom/Alarms/Security Manufacturing Equipment
HVAC Systems Elevators/Escalators Home Theater Systems
Residential / Commercial Data & Software Point of Sale TV & Radio Broadcast Equipment
Electrical Distribution Systems Police & Fire Radio Emergency Systems
Other
Section 9 - LOSS DESCRIPTION
 
 
 
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