At any time, you may perform one of the following actions:
	Save this claim so you can return to it later.
	No processing is performed by Schinnerer until the claim is submitted.
	Submit this claim to Victor O. Schinnerer for processing.
	On submission, Schinnerer will begin to process this claim. Confirmation of this submission will be sent via email to those parties whose email addresses have been provided below.
	Need to return to a saved claim? Enter its tracking number in our tracking window.
	To learn more about the features of our online forms, visit our help page.
	All required fields must be completed prior to submission of this claim.
	Contact Information (for person completing this form)
	1)   Today's date: 2)   Person reporting: 3)   Company: 4)   Phone number: 5)   Fax number:  6)   Email address:      Upon submission, a notification will be sent to this email address (if provided).
	Insured Information
	1)   Name of insured: 2)   Policy number: 3)   Address of insured: 4)   Contact person: 5)   Business phone: 6)   Email address:  7)   Broker's email address:      Upon submission, a notification will be sent to the email addresses provided above.
	Claimant Information
	1)   Name of claimant: 2)   Type of claimant: Buyer Seller Other      If 'Other', please specify:  3)   Address of claimant:
	Incident/Claim Information
	1)   How were you notified of this claim? 2)   Date of claim notification: 3)   Date of transaction/incident: 4)   Has a suit been served? Yes No      If 'Yes', please complete the following:   a. Date the suit was served:    b. County/State/Court:    c. Claimant's attorney:  5)   Name(s) of employee(s) involved: 6)   Address of property involved: 7)   Details of incident or allegation:
	Attachments
	You may attach one or more supplemental documents to provide additional information.   Please check here if you want to fax documents that are not in electronic form. You may fax them to the attention of "Real Estate Claims" at (301) 951-5444.   For faxed documents, be sure to reference the tracking number that will be provided when you save or submit this claim.
	Warning
	Colorado, Florida, Hawaii, Kentucky, Louisiana, Maine, New Jersey, New York, Ohio, Oklahoma, Pennsylvania and Virginia Residents Only Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime (for New York residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Colorado residents only: Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder of claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.) (For Hawaii residents only: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.) (For Virginia residents only: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.)
	When you're ready, you can...
	Save this claim so you can return to it later.   No processing is performed by Schinnerer until the claim is submitted. Need to return to a saved claim? Enter its tracking number in our tracking window.   Submit this claim to Victor O. Schinnerer for processing.   On submission, Schinnerer will begin to process this claim. Confirmation of this submission will be sent via email to those parties whose email addresses have been provided above.
Victor O. Schinnerer & Co. Inc. Two Wisconsin Circle Chevy Chase, MD 20815-7022 Telephone: 301-961-9800 or FAX: 301-951-5444 Email: vos.info@schinnerer.com Website: www.schinnerer.com