Submit a Claim

To submit a claim, you have three options: Email submission, Fax submission, or Online submission

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Email Submission

Please click here to download the claim worksheet. Fill in as much detail as possible, save the document with your corresponding claim number and email it back to claims@replacementsource.com.

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Fax Submission

Click here to access the fax cover sheet. Once you've completed the form, print it and attach a full list of the property you would like evaluated and fax it to 800-275-5957. We'll take it from there!

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Online Submission

Date of Loss:

Claim Number:

Adjuster Information

First Name:


Last Name:


Insurance Company:


Email Address:

 

Phone Number: (xxx-xxx-xxxx)


Ext:


Fax Number: (xxx-xxx-xxxx)

Policy Holder Information

First Name:


Last Name:


Address:


City:


State:


Zip:

 
Commercial Policy?
Yes No

Primary Phone: (xxx-xxx-xxxx)

 
Secondary Phone: (xxx-xxx-xxxx)

 
Ext:


Email Address:

 

Policy Information

Policy Type:
RCV ACV

Deductible:
Collect Deductible

Applicable Limits:

Authorization

Replacement Authorized:
Yes No

By selecting "Yes" in the "Replacement Authorized" box, you are giving your approval for ReSource to ship the replacement items directly to the insured and further agree to make the check payable to ReSource for the items the insured requests.

Comments:

Your Items

Item Description:	Age:	Qty:	Original Cost:

I have another item.