Submit a Claim Submit a Claim Assignment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Policyholder Name *FirstLastAdditional Policyholder NameFirstLastPolicyholder Email *Additional Policyholder Email Name Phone of Policyholder Phone *Additional Policyholder Phone What State is Loss Located? *--- Select Choice ---ColoradoFloridaGeorgiaNorth CarolinaSouth CarolinaTexasAddress of Loss *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of Loss *Contractor Company Name *Contractor Name *FirstLastContractor EmailContractor PhoneReferral SourceReferral Source EmailCause of Loss *--- Select Choice ---WindFloodHailWind/HailHurricaneTornadoWaterFirePipe BreakVandalismMarine/AircraftDescription of Loss/Damage *Status of ClaimNewSupplementLoss Below DeductableDeniedOtherPolicy Number *Claim NumberFile Upload Drag & Drop Files, Choose Files to Upload You can upload up to 3 files. Please Upload Your Policy Declaration Page and any Pertinent Claim Documentation HEreCheckbox Items *Third ItemSMS Terms and Conditions 1. SMS Consent Communication: The information (Phone Numbers) obtained as part of the SMS consent process will not be shared with third parties for marketing purposes. 2. Types of SMS Communications: If you have consented to receive text messages from Rockwall National Public Adjusters, you may receive messages related to the following: • Appointment reminders • Follow-up messages an claim updates • Billing inquiries 3. Message Frequency: Message frequency may vary depending on the type of communication. For example, you may receive multiple SMS messages per week related to your claim. 4. Potential Fees for SMS Messaging: Please note that standard message and data rates may apply, depending on your carrier’s pricing plan. These fees may vary if the message is sent domestically or internationally. 6. Opt-Out Method: You can opt out of receiving SMS messages at any time. To do so, simply contact us directly to request removal from our messaging list. 7. Help: If you are experiencing any issues, you can get help directly from us by contacting our office • Additional Options: • If you do not wish to receive SMS messages, you can choose not to check the SMS consent box on our forms. 8. Standard Messaging Disclosures: • Message and data rates may apply. • You can opt out at any time by texting "STOP." • For assistance, text "HELP" or visit our [Privacy Policy] and [Terms and Conditions] pages. • Message frequency may varySubmit
