STS Equipment Restoration

STS Equipment Restoration LLC

INSURANCE CLAIM ASSIGNMENT FORM

To assign us a job electronically, fill out this form, and hit the Submit button at the bottom. Even if you don't have all the information, feel free to get started now. Fill in the information you do have, click the Submit button at the bottom of the form, and an STS representative will contact you via phone or e-mail to fill in the blanks.

In order to expedite the billing process, payment authorization is required from the insured. Please print the Payment Authorization Form, fill-in all information, sign and fax to our office.

* Required

CONTACT INFORMATION
Contact Name *
E-mail Address: *
Company
Address
Address 2
City
State
Zip
Phone
Fax


CLAIM INFORMATION
Carrier Name
File #
Date of Loss
Insured
Address
Address 2
City
State
Zip
Phone
Fax
Email
Claimant / Contact
Address
Address 2
City
State
Zip
Phone
Loss Location (if different)
Address
City
State
Zip


LOSS INFORMATION
Describe Loss
Scope of Service
Other Notes


REPORTING INFORMATION
Report To	You Other
Name
Company
Address
Address 2
City
State
Zip


INVOICE INFORMATION
Invoice To	You Other
Name
Company
Address
Address 2
City
State
Zip




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