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Subrogation Referrals
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Subrogation Referral or Inquiry?
*
Please Select
Subrogation Referral
Inquiry
Please choose whether this is a subrogation referral or inquiry
Initial Referral or Supplemental Submission?
*
Please Select
Initial Referral
Supplemental Submission
Please select supplemental if the claim has previously been referred to SubroSmart
Company Name
*
Enter your company name
Company Type
*
Select Option
TPA
Coverholder / MGA
Independent Adjuster
Insurer / Syndicate
Broker
Company / Insured
Select your company type
Your Name
*
First Name
Last Name
Your Phone
Enter your phone number (if international please include country code)
Your Email
*
Carrier or Company Claim?
*
Please Select
Insurance Carrier
Company / Non-Insurer Claim
Please select the carrier type. If within deductible or if there is no claim under an insurance policy, select Company / Non-Insurer
Carrier Type?
*
Lloyds
Non-Lloyds
Multiple Subscribing Carriers?
Yes
No
Date of Loss
Month
Day
Year
Please enter the date of loss.
Your Claim Number
*
SubroSmart Number
Leave blank if unknown
Inquiry Request
*
Insured Name
*
Lead Carrier / Underwriter
*
Additional Underwriters / Carriers
Add
Remove
Please press the "+" on the right to add multiple carriers subscribing to this claim
Unique Market Reference / UMR(s)
Add
Remove
Broker
Coverholder
Policy Number
Line of Business
Unknown
Auto Physical Damage (APD)
Cargo & MTC
Property
Cyber
Personal Property
Shippers Interest
Specialty
Other
Claim Type
Please Select
Unknown
Collision
Fire
Water
Theft / Vandalism
Defect
Equipment Damage
Impact
Mechanical
Product Liability
Wildfire
Workmanship
Other
Claim Status
Please Select Payment Status
Paid (Final)
Paid (Partial)
Unpaid
Unknown
Deductible Size
No Deductible
Between $1 - $25,000
Between $25,001 - $100,000
Over $100,000
Estimated Claim Amount
Please provide an estimate of the indemnity
Jurisdiction
*
Please Select
United States
Canada
United Kingdom
Canadian Province
*
Please Select
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Loss State
*
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Policy State
Select State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Loss Location
Please paste the loss address if available
Claim / Referral Summary
Please provide a description regarding the submission including a summary of the claim, important information that may be unique, or additional detail if a supplemental submission.
Upload Complete Claim File
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