About | National Subrogation Services, LLC (NSS)

Referral Form

Print Version (send via Mail)

Assign To:

Completed by NSS

Manager:

Completed by NSS

Matter #:

Completed by NSS

Claim #:

DOL:

Statute of Limitations:

Client:

Insured:

Adjuster:

Phone #:

E-Mail:

Loss Location:

Total Claim Amt. (incl. ded.)

Deductible:

Target:

Type of Claim: (Check all that apply)

	1st Party Property
	Auto Collision/Comprehensive
	Workers Comp
	Pip/Med Pay
Name(s) of Injured Party:
	3rd Party Property Damage or Bodily Injury
	Other

Responsible Party:

Responsible Party's Carrier:

Facts of Occurrence:

Need to attach additional information?

Please remember to send Accord, all Investigation, Proof of Damages, Proof of Payment and all file Notes. You can attach them by email here, or send by mail/fax to the address below. Please be sure to include the claim number in the subject field.

National Subrogation Services
350 Jericho Turnpike, Ste. 310
Jericho, NY 11753
(516) 949-3620
(516) 949-3621 fax