Claim Adjuster’s Worksheet

Purpose

Purpose of This Inquiry

Jewelry Replacement

Jewelry Salvage

Insurance Company Details

First name

Last name

Email Address

Insurance Company

Your Phone Number w/Ext

Fax Number

Street Address

City

State

Zip

Insured Party Details

Insured’s First Name

Insured’s Last Name

Policy/Claim #

Description of Jewelry Items

Comments