File A Claim - D&H Alternate Risk Solutions

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Blank Form (#11)

First Name

Last Name

Phone/Mobile

You are the member Yourself

Yes

Member's First Name

Member's Last Name

Member's Address

Address Line 1

City

State

Country

Member's Phone/Mobile

Want to add different contact info?

Yes

Contact Person's First Name

Contact Person's Last Name

Contact Person's Phone/Mobile

Contact Person's Email

It's a member self claim or by attorney?

Claim By Self

Claim By Attorney

Claimant's First Name

Claimant's Last Name

Claimant's Address

Address Line 1

City

State

Country

Claimant's Phone/Mobile

Attorney Name

Attorney Phone/Mobile

Attorney's Email

Attroney's Address

Address Line 1

City

State

Zip Code

It's an auto claim?

Yes

Year

Make

Model

Vin#

Plate Number

Driver of vehicle involved in loss?

Location of vehicle for appraisal purposes

Address Line 1

City

State

Country

Location of damage on vehicle and estimated damages.

Address Line 1

City

State

Country

Date Of Birth

Social Security #

Injury information will be needed (DOB & SS number will need to be redacted)

Date / Time Of Loss

Address

Address Line 1

City

State

Country

Brief description of loss.

Additional information

Upload P/R (police report)

Choose File

LOR (letter of representation)

Choose File

NOTC (Notice of Tort Claim)

Choose File

Estimates/Photos

Choose File

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