Interstate Public Adjusters, LLC 38 Hesstown Road Millville, New Jersey 08332 (800) 334-9990 or (215) 333-3388 Fax # (856) 327-5012 www.interstateadjusters.com

Claim Request & Questions Form To report a claim to us, or if you have a question as to whether your damage is covered, complete this form and submit it to us. You may also print this form and fax it to 856-327-5012 or call us at 800-334-9990 Name: Company: (if damage occurred here) Address: City/State/Zip: E-Mail: Telephone: Fax: How did you first learn about us? Internet Yellow Pages Referral Other Type of Claim? Water Damage Smoke Damage Fire Damage Wind Damage Storm Damage Theft/Vandalism Other Details of Claim (please be as specific as possible, where the damage occurred, how it occurred etc.)