Report An Loss | BELFOR USA

First Name

Last Name

Primary Telephone Number

Alternate Telephone Number

Are You The Property Owner?

Is This An Emergency?

Company

Email Address

Are you an Insurance Professional?

Property Owner Name

Address of Damaged Property #1

Address of Damaged Property #2

City

State

Zip

Country

Name of Insurance Carrier

Loss Location Type

Loss Type

Details of Loss

Comments

Approximate Square Feet of Structural Damage

Description of Loss

Rooms Affected

Materials Affected

Please Describe Contents Damaged In Loss

Has Insurance Company Been Notified

Insurance Claim Number

Name of Insurance Adjuster

Insurance Adjuster Phone

Name of Insurance Agent/Broker

Insurance Agent/Broker Phone

Special Instructions

Please Hit Submit Button One Time Only For Each Loss

Report A Loss