NICE Network, Inc.
Phone 800-837-6423 or 859-814-0061 •
Fax 800-486-8110
www.nicenetwork.com
Adjuster
Date
Company
E-mail
Address
Ph#
Ext
City/ST/Zip
Fax
Policy/Claim/File#
Date of Loss
Insured
Ph#
Address
Fax#
City/ST/Zip
Contact
Contact email
Reported Cause of Loss:
<Select Cause of Loss>
Lightning
Theft
Water
Fire
Transit
Mechanical Breakdown
Power Surge
Other
Cause of Loss Comments:
Coverage:
<Select Coverage>
R/C
ACV
3rd Party
Deductible $
Description of Equipment Reported as Damaged or Stolen:
Computer
Telephone
Office Equipment
Alarm System
Audio/Video
Other Equipment
Comments:
Reported Scope of Damage, Current Status & Location of Equipment:
Technician
Company
Ph#
Technician
Company
Ph#
Any Documents Already Received & Being Sent to NICE Network:
Property Loss Notice
Repair/Replacement Estimate
Police Theft Report
Original Purchase Invoices
Repair/Replacement Invoice
Inventory of Equipment
Additional Information/Documents Received of Requested:
SERVICES REQUESTED FROM NICE NETWORK:
NICE Network’s Complete Evaluation Service
Arrange Inspection of Equipment
Verify Inventory Description & Configuration of Equipment
Verify Market Values of Equipment
Evaluate/Verify Reported Cause of Loss
Order GDS Lightning Verification Report
Evaluate Scope of Damage & Repair/Replacement Options
Evaluate Potential Salvage Value of Equipment
Special Instructions:
File Attachment(s):