Raphael & Associates General Liability Claim Form
  • Client Information
  • Name*
  • Company*
  • Street*
  • City*
  • State*
  • ZIP Code*
  • Home Phone*
  • Work Phone*
  • Email*
  • Claim Number*
  • Insured Information
  • Name*
  • Street*
  • City*
  • State*
  • ZIP Code*
  • Home Phone*
  • Work Phone*
  • Loss Information
  • Loss Type*
  • Date of Loss*
  • Contact Our Insured and:*
  • Additional Comments*
  • Contact the claimant(s) and:*
  • Additional Comments*
  • Miscellaneous:*
  • Additional Comments*
  • Loss Description*
  • Subject Individual
  • Name*
  • Date of Birth*
  • Social Security Number*
  • Street*
  • City*
  • State*
  • ZIP Code*
  • Home Phone*
  • Work Phone*
  • Email*
ABOUT US
Raphael & Associates is a TPA and claims adjusting company internationally recognized for its exceptional service and unsurpassed reputation of nationwide claims handling. We understand the importance of adapting to the demands of a dynamic market and tailor our services to our client's specific needs. Our mission is simple: to provide outstanding service, extraordinary professionals and the best that technology has to offer.

Raphael & Associates

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