Date of Loss

Contact Information

Claim Number

First Name

Last Name

Company Name

Address

City

Postal Code

Phone

Fax

Primary Contact Email

Insureds Information

Insureds First Name

Insureds Last Name

Insureds Phone

Additional Site Contact Info (as applicable)

Billing Information

Please complete this section if billing information differs from the contact information above.

First Name

Last Name

Address

City

Postal Code

File Information

Please provide any special instructions and job request details in this section.

Loss Location

Address

City

Postal Code

Scope of Work

Evidence

If evidence is being sent in conjunction with this assignment, please complete the following fields.

Submission of evidence with this form, is an agreement between the submitting party named as the primary contact and JENSEN HUGHES that any such evidence is covered by the JENSEN HUGHES Evidence Storage Agreement and Liability Statement which is available upon request.

File Upload

Evidence Details

Please call the 24 hour service desk on +44 (0)141 639 6611, alternatively, please email instructus.UK@jensenhughes.com or instructus.ie@jensenhughes.com

Date of Loss

Contact Information

Insureds Information

Billing Information

File Information

Evidence

To ensure essential website functions work properly

Statistics & Marketing