Custom Creations

Jewelry Sales and Replacement

Custom Creations
24913 123rd Ave NE
Rogers, MN 55376
ph: 612-590-3315
fax: 763-428-3566
tim@customcreationsmn.com

Claim Form

Is it OK to contact insured for possible replacement?

Special Instructions or Notes... (do NOT add item description here)

___________________________________________________________________________

Insurance Company:

Insurance Company's Address

Insurance Company's City, State, Zip

Adjuster's Name

Adjuster's EMail

Adjuster's Phone

_______________________________________________________________________

Insured's Contact Information:
Name

Address

City, State, Zip

Work Phone

Home / Cell Phone Number

Email Address

_______________________________________________________________________

Insurance Claim Number

Date of Loss

Non-Sched Coverage Limit (Please enter dollar amount)

_______________________________________________________________________

Item #1 - Description

Item #1 - Coverage Type

Item#1 - Deductible (enter dollar amount)

Item #1 - Sched. Coverage Limit (enter dollar amount)

_______________________________________________________________________

Item #2 - Description

Item #2 - Coverage Type

Item #2 - Deductible (enter dollar amount)

Item #2 - Sched. Coverage Limit (enter dollar amount)

_______________________________________________________________________

Will Additional Items, Appraisals, or Other Documents Be Faxed To 763-428-3566?

Yes No

Submit Your Message:

Custom Creations
24913 123rd Ave NE
Rogers, MN 55376
ph: 612-590-3315
fax: 763-428-3566
tim@customcreationsmn.com