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Submit a Claim Assignment
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Florida Boat Surveying
Submit your claim assignment online, or print this form and fax it to 727-343-3300.
Express Claims may also be submitted using this form.

Adjuster Information

Your E-mail Address (required):


Date Submitted:


Company:


Adjuster:


Phone:


Ext.:


Fax:


Street Address:


City:


State:


Zip Code:


Loss Information

Date of Loss:


Claim #:


Name of Insured:


Home Phone#:


Work Phone#:


Street Address:


City:


State:


Zip Code:


Type of Loss:


Location of Boat:


Phone:


Description of Boat

Year:


Length:


Hull ID#:


Manufacturer / Model:


Boat name:


Description of Engine

Year:


Horsepower:


Manufacturer/Model:


Policy Information

Replacement Option:   ACV Policy: (choose one)

Policy Limit of Vessel:


Deductible:



*If this is an Express Claim, please specify below.


      
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