Assign a Claim

/Assign a Claim

Thank You for choosing Moe & Nevin Insurance Adjusters to handle your claim. We will strive to meet your needs and exceed your expectations. To serve you with the utmost efficiency all claim assignments are processed and distributed accordingly through our corporate office located in Duluth, MN.

Attach Accord form, Dec Sheet, Etc.File types: PDF, TXT, XLS, XLSX, DOC, DOCX, JPG, JPEG, PNG, GIF

Client Information:

Name of person entering claim information:*

Name of person to whom to report:

Name of your company:

Mailing Address:

Line 2 Mailing Address:

City:

State:

Zip:

Phone Number:*

Fax Number:

Email Address:

Claim Number:

Insured Information

Insured Name:*

Insured Address:

Insured Address 2:

City:

State:

Zip:

Loss location if different than insured's address above:

Insured's Phone 1: *

Insured's Alternate #:

Insured's Phone 2:

Insured's email:

Loss Information

Date of Loss:

Cause of Loss:

Description of Loss:

Policy Information

Policy Form:

Policy Number:

Effective Dates:

Listed Mortgagee:

Coverage Limits

Coverage A:

Coverage B:

Coverage C:

Coverage D:

Other:

Deductible:

Commercial Coverage

Building:

Business Personal Property:

Business Income:

Other:

Please describe any additional coverage that may apply:

Please describe any exclusions or coverage modifications that may apply:

Please enter any special instructions: