Property & Auto Case Submission "*" indicates required fields Referrer’s Contact InformationReferrer's Email Address* Referring Individual’s Name*Referring Company Name*Phone Number*Insured/Policyholder InformationFull Insured/Policyholder Name*Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* New Loss InformationUnderwriting Carrier Name*Policy Number*Claim Number*Date of Loss MM slash DD slash YYYY Loss Location* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Was an Expert Retained?* Yes No Provide name and firm:*Type of Loss – Check All That ApplyProperty – Structural Electrical Fire Cooking Fire HVAC-Related Fire Faulty Wiring Appliance Malfunction Construction Defect – Roofing Construction Defect – Plumbing Structural Collapse Building Code Violation Property – Water Frozen Pipe Pipe Burst Sewer Backup Appliance Leak Roof Leak HVAC Condensation Sprinkler System Malfunction Property – Storm / Weather Hail Damage Wind Damage Tree Impact Ice Damming Lightning Strike Property – Miscellaneous Theft/Burglary Vandalism Defective Product Caused Damage Utility Company Negligence Neighbor Negligence Neighbor Tree Loss Product Defect Yes No Who is the Manufacturer?Motor Vehicle Loss Yes No Was a Police report taken? Yes No Is Claim fully Adjusted?* Yes No What was the indemnity?*What was the deductible?*Was the deductible waived?* Yes No Brief Description of Loss:Damages Paid (To Date)PropertySelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+ContentsSelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Additional Living ExpensesSelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Business PropertySelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Business – Lost Rent (Loss of Use) PaidSelect An Option10K-25k25K-50K50K-75K75K-100K100K-150K150K-200K200K-250K250K-300K300K-350K350K-400K400K-450K450K-500K500K+Adverse Party Information (if known)Target(s)Name of Attorney or PAFirm NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Upload Case FilesFile Upload Drop files here or Select files Max. file size: 50 MB. Important Notice Regarding Case Referral SubmissionsSubmitting information through this online referral form does not establish an attorney-client relationship between you and DSB&C or any of our attorneys. Please do not include confidential or sensitive information in your submission until you have spoken directly with one of our attorneys and formally established a privileged attorney-client relationship. If you are not presently a client of DSB&C, any information you provide through this form may not be protected by attorney-client privilege. This referral portal and our invitation to contact us should not be interpreted as a solicitation for legal services or as creating any attorney-client relationship. Additionally, this should not be construed as confirmation that our attorneys are available to provide legal representation in jurisdictions where they are not licensed to practice law. 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