Financial Claims Incorporated:

Home
Company Overview
Our Services
Rates and Terms

Claim Form

Payment Choices
Contact Us
Links
Status Now
Passive Accounts

Online Claim Form

Fill out the following form to submit a claim online. You may also Download Alternate Printable Versions of this Form if you prefer. * Denotes required fields.

Client Info

Please provide us with your contact information so that we may reach you upon collection of this claim, or if we have any further questions.

*Company:
Address1:
Address2:
*City: *State: Zip: +4 (optional):

Company Contact Person

First Name:
Last Name:
*Email:
Fax: ()-- Phone: ()-- Ext.(optional):

Claimant Info

Please provide as much information as possible regarding the claimant to help us resolve the account for you more effectively. This is especially helpful in claims that require skip tracing.

Company:
First Name: Middle Name/Initial: Last Name:
Phone: ()-- Address1:
Address2:
City: State: Zip: +4:

Claim Information

*Placement First Placement Second Placement Other
*Loss Date (mm/dd/yyyy): *Principal$: *Total$:
Insured:
Policy Number: Claim Number:

Passive Accounts

Find out about our Passive Account System.
Pay desk or passive file: Yes No
Copy and paste the details of your pay desk agreement:

Return Information

*Return by: Email
Additional Information or Comments:

Submit Form