Electronic Catastrophe Assignment

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Electronic Catastrophe Assignment................................Rimkus Consulting Group, Inc.

Field Names in RED Are Required Fields.

Insurance Company:

Company Name:

Address:

City:

State: Zip Code:

Email:

Telephone: Fax:

Your Name:

Cell No:

Claim Number:

Policy Number:

Your Insured:

Tel: Cell or Alt No:

Location of Occurrence:

City:

State: Zip Code:

Date of Loss:

Description Of Loss:

Services Requested from Rimkus:

(Please Check Box)

Site Visit	Mechanical Inspection	Structural Analysis
Please Describe Exactly what you want the engineer to determine:(description box)

Adjustment Company:

Address:

City:

State: Zip Code:

Telephone:

Adjuster: Cell No:

Email:

File Number: Fax No:

Paperless report and invoice required?

Yes	No
(If the yes box is checked an email address is required.)

Catastrophe Hotline: (866) 408-4228 | Fax: (800) 228-2223 | Email: catclaims@rimkus.com