Forms Quintana

Report Loss

Generated by (name):

Insurance Company:

Assured:

Assured Address:

Country:

Name of the person who need to talk:

Assured Phone:

E-mail:

Date:

Claim Number:

Branch:

Policy Number:

Sum Insured:

Coverage

Type of Damage:

Remarks:

Assured Estimate:

Adjuster:

Name of the person who give the adjustment:

Date of the Order:

Number of the Adjustment:
Important:	For better care is requisite to fill as many fields requested, thanks