PCA Adjusters Ltd. Online Claims Form

PCA ADJUSTERS LTD. ONLINE CLAIMS FORM

Please complete and submit the following information regarding your claims assignment.

Your assignment will be sent our nearest branch office.

Note: Fields marked with an asterisk* are required

Company Name:*		Contact Name:*
Address Line 1:*		Address Line 2:
City:*		State/Province:*
Country:		Zip/Postal Code:*
Phone Number:*		Fax Number:
Email:

Name of Insured:*		Address:
City:*		State/Province:*
Zip/Postal Code:*		Contact Phone 1:*
Contact Phone 2:

Broker

Policy Number

Policy Effective Date (mm/dd/yy)?

Coverages

Type of Loss*

Date of Loss (mm/dd/yy)*

Customer Claim Number

Location Of Loss

Actions or Special Reporting Instructions*

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Please feel free to email us with any questions or comments.

PCA Adjusters Ltd.
The Chambers of Queensview, 2725 Queensview Drive, Suite 100 Ottawa, Ontario K2B 0A1
Tel: (800) 722-9556 | Fax: (613) 726-0000

Broker
Policy Number
Policy Effective Date (mm/dd/yy)?
Coverages
Type of Loss*
Date of Loss (mm/dd/yy)*
Customer Claim Number
Location Of Loss
Actions or Special Reporting Instructions*

Copyright © 2007 PCA ADJUSTERS LTD.