JSON Data Form OSA
Adjuster Information
Adjuster Name:
Adjuster FCN Number:
*
Adjuster Phone Number:
Adjuster Email:
Agency Information
Agent Name:
Agent Cell Number:
Agent Email:
Mortgage Company:
Policy Information
Policyholder Name:
*
Policyholder Email:
Primary Phone Number:
Secondary Phone Number:
Policy Number:
*
Claim Number:
*
Policy Start Date:
Policy End Date:
Insurer and Adjusting Firm Information
EDN:
Insurer:
Insurer Street:
Insurer City:
Insurer State:
Insurer Zip:
Adjusting Firm:
File Number:
*
Firm Street:
Firm City:
Firm State:
Firm Zip:
Firm Phone Number:
Policyholder Loss Address
Loss Street:
Loss City:
Loss State:
Loss Zip:
Policyholder Mailing Address
Same as Loss Address
Mailing Street:
Mailing City:
Mailing State:
Mailing Zip:
Claim and Property Details
Date of Loss:
*
Date of Assignment:
*
Date of Contact:
Date of Inspection:
Date of Construction:
Firm Date:
Flood Zone
Firm Status:
Post Firm
Pre Firm
Coverage Details
Coverage A Building:
Deductible A Building:
Coverage B Personal Property:
Deductible B Personal Property:
Coverage Other Structures:
Deductible Other Structure:
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