Loss Report

Loss Report
If you need to report a loss or receive help from F.Lax, please fill out the form below. An F.Lax representative will get in touch with you as soon as possible.

If you are an agent or adjuster, please complete the section For Agents/Adjusters Only.

For questions, please call 1-800-547-1914.
First Name *
Last Name *
Phone Number *

- Area Code Phone Number
Cell Number

- Area Code Phone Number
Do you own the property?

Yes No
Is this an emergency?

Yes No
Company
Email *
Are you an Insurance Adjustor?

Yes No
Property Owner Name
Property Address *
City *
Zip Code *
Name of Insurance Carrier
Type of Building *
Type of Building

Residential Commercial Industrial Other
Date of Loss *

- Month - Day Year
Type of Loss

Fire Water Storm Biohazard
Loss Details
Photo 1
2 MB limit per file. PDF, JPG, GIF formats acceptable.
Photo 2
2 MB limit per file. PDF, jpg, gif formats acceptable.
Photo 3
2 MB limit per file. PDF, jpg, gif formats acceptable.
Comments
For Agents/Adjusters Only
Approximate Sq.Ft. of Damage
AGENTS-ADJUSTERS ONLY
Type of Loss
AGENTS-ADJUSTERS ONLY
Rooms Affected
AGENTS-ADJUSTERS ONLY
Contents Damaged in Loss
AGENTS-ADJUSTERS ONLY
Claim Number
AGENTS-ADJUSTERS ONLY
Adjuster Phone
AGENTS-ADJUSTERS ONLY
Has Insurance Company Been Notified?

Yes No
Insurance Adjuster Name
AGENTS-ADJUSTERS ONLY
Insurance Agent Name
AGENTS-ADJUSTERS ONLY
Agent/Broker Phone
AGENTS-ADJUSTERS ONLY
Additional Instructions
AGENTS-ADJUSTERS ONLY
Should be Empty:

For Agents/Adjusters Only