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Adjuster Date
Company E-mail
Address Ph# Ext
City/ST/Zip Fax
Policy/Claim/File# Date of Loss
Insured Ph#
Address Fax#
City/ST/Zip Contact
Contact email
Reported Cause of Loss:
Cause of Loss Comments:
Coverage: Deductible $
Description of Equipment Reported as Damaged or Stolen: Computer Telephone Office Equipment Alarm System Audio/Video Other Equipment
Reported Scope of Damage, Current Status & Location of Equipment:
Technician Company Ph#
Technician Company Ph#
Any Documents Already Received & Being Sent to NICE Network:
Property Loss Notice
Repair/Replacement Estimate
Police Theft Report
Original Purchase Invoices
Repair/Replacement Invoice
Inventory of Equipment
Additional Information/Documents Received of Requested:
NICE Network’s Complete Evaluation Service
Arrange Inspection of Equipment
Verify Inventory Description & Configuration of Equipment
Verify Market Values of Equipment
Evaluate/Verify Reported Cause of Loss
Order GDS Lightning Verification Report
Evaluate Scope of Damage & Repair/Replacement Options
Evaluate Potential Salvage Value of Equipment
Special Instructions:
File Attachment(s):

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