“Taking the Insurance Umpire Process
into the 21st Century” SM

UMPIRE SERVICE REQUEST

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Select Type Of Service Requested:

Select Type Of Service Requested

INSURED & CARRIER INFORMATION

INSURED

PROPERTY ADDRESS

POLICY NO

CLAIM NO

CARRIER

INSURED TELEPHONE NO

INSURED EMAIL ADDRESS

CONTACT FOR INSPECTION

APPRAISER INFORMATION

PA APPRAISER INFO

Name

Tel

IA APPRAISER INFO

Name

Tel

COURT INFORMATION (IF APPLICABLE)

COURT CASE NO

County/Circuit

Federal District

Court Ordered

Completion Date

ATTORNEY INFORMATION

INSURED ATTORNEY

Firm

Assigned to

Tel

CARRIER ATTORNEY

Firm

Assigned to

Tel

PLEASE ATTACH THE FOLLOWING DOCUMENTS

For Appraisal & Umpire Assignments, upload each parties Estimate, Photo Logs and Expert Reports. For Appraisal Assignments, also provide, if appropriate, Carrier Correspondence, and IA/PA/ATTY Correspondence, as well as any other appropriate documentation.

Select Files

Upload Files

Carrier Field Adjustment

Carrier Correspondence

Carrier Field Adjustment

Carrier Appraiser Estimate

Carrier Photo Log

Public Adjuster Estimate

Insured Appraisal Estimate

Insured Photo Log

Miscellaneous Carrier Documents

Miscellaneous Insured Documents

NOTES

UMPIRE SERVICE REQUEST

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