Assign a New Claim

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Claim Number *

Date of Loss *

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Adjuster Name

Adjuster Phone

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Adjuster Email *

Insurance Company

Insured's Name

First

Last

Claimant's Name

First

Last

Phone *

Email

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Inspection Location

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Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Color

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Vehicle Identification Number (VIN)

Vehicle License Plate #

Any Special Instructions

File Upload

Click or drag a file to this area to upload.

Checkboxes

• I Agree to Marketing Emails from Complete Claims Service (optional)

Submit

We at Complete Claims also allow claim submissions through email. You may send your claim to admin@completeclaims.com. You can also call or fax the office directly.

Telephone: 516-935-8780
Fax: 516-939-0520