LAIGA Submission Form LAIGA Submission Form Carrier/Third Party Information Company Name * Company Type GRS Contact Name Wayne Camp-BellMike MyersCheryl Cervantes GRS Contact Email Loss Information LAIGA Claim Number * Date of Loss Loss Description Loss Location Address * Loss Location Address Loss Location Address Loss Location Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Building Type CommercialResidentialAgriculturalIndustrialInstitutional Service(s) Requested Property Inspection Spot Check/Confirm Dimensions Repair Protocol Estimate Review Building Consultant Requested Dan DoubravaGreg LandesHarold AdamsJeff McClure Assignment Handling Instructions File Upload Drop a file here or click to upload (property loss notice, estimates, photos, drawings, etc.) Choose File Maximum file size: 10MB GRS Adjuster Information Contact GRS Adjuster YesNo GRS Adjuster Name Michael ThompsonJeffrey HallStephen PeltierWilliam Stallcup GRS Adjuster Phone & Email Insured Information Contact Insured YesNo Insured Name Insured Name First First Last Last Insured Phone Insured Email Public Adjuster Information Contact Public Adjuster YesNo Public Adjuster Name Public Adjuster Name First First Last Last Public Adjuster Phone Public Adjuster Email Attorney Information Contact Attorney YesNo Attorney Type Defense CounselPlaintiff Counsel Attorney Name Attorney Name First First Last Last Attorney Phone Attorney Email Captcha If you are human, leave this field blank. Submit Start Over
