Goldstone Services: Contact Us

EClaim

Online Preliminary Claim Report

Welcome to Goldstone Services ECLAIM (Online preliminary electronic submittal form). In our efforts to make the process of adjusting as simple and as easy as possible we have developed this simple online form for your convenience. Please fill in all the appropriate fields with as much detail as possible.

With all first time submittals we will send you a response email. In that email we will also include your own personalized EClaim form so that you can submit claims from your computer without having to enter your personal information every time. We code your information into the personalized form so all you do is submit the insured's information with each claim.

Please fill out this form as complete as possible, using the TAB button to move from field to field. When you are done, click the SUBMIT button to send the form.

(*=Required)

Adjuster Information:
*Name
*Company
*Address
*City		*State		*Zip
*Phone		Ext
*Fax
*Email

Insured Information:
*Name
Address
City		State		Zip
Phone			Mr./Mrs./Ms.
Other			Mr./Mrs./Ms.
Other			Mr./Mrs./Ms.

Insurance Information:
*Claim #:
Have you contacted the insured party?
Is it okay for Goldstone to call the insured party?
Scheduled amount				(blank if N/A)
Non-scheduled amount				(blank if N/A)
Deductible
Will the deductible be applied elsewhere?
Comments & Descriptions:
Would you like a receipt of acknowledgement?
	Yes, via email Yes, via fax Yes, via my phone No,thank you

_______

If you have a document concerning this claim that you wish to send us, you may copy and paste it into the comments field of this form, send it to claims@gldstone.com as an E-mail attachment, or fax it to us at 801.575.2199.

Home