insurance Claim Submission Form

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Firm Information

Great Neck Office
55 Northern Boulevard, Suite 302
Great Neck, NY 11021
(718) 352-4800

(917) 251-6651
(24 Hour Urgent Matters)

Quick Insurance Claim Submission Form - Please allow two hours for a response from
attorney. Your submission will remain confidential and there is no obligation or fee for a
claim evaluation or consultation.

Fields marked with * are required

Name *

Loss location *

Date of loss *

Phone *

E-mail *

How would you like to be contacted? *

Briefly describe your claim? *

Has your claim been submitted to your insurance company? *

Has your claim been denied? *

Do you currently have representation by either an attorney or public adjuster? *

Upload any documents important for the evaluation of your claim, such as any letters from the insurance carrier, fire report, police report, and representative photographs. Please note, for denied claims a copy of the denial letter should be provided. All documents may also be sent by fax to 718-732-2110. 5 file max. File types; doc, docx, ppt, xls, pdf, jpg, gif, png, zip

Document Upload

Max file size allowed: 1.95 MB

E-mail a copy of this message to your own address.

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Greenblatt & Agulnick, P.C., in Great Neck, New York, provides legal advice and representation for individuals and corporate entities in communities throughout the New York City region and Long Island, including Manhattan, Queens, Bronx, Brooklyn, Richmond, Long Island City, Garden City, White Plains, Roslyn, Plainview, Manhasset, Westchester, Rockville Center, Searingtown, the Hamptons, Larchmont, Dix Hills, Yonkers, Little Neck, Port Washington, Kew Gardens, Forest Hills, Astoria, Mineola, Glen Cove, Hempstead, Levittown, Flushing, Jamaica, Floral Park, Hewlett, Jericho, Bayside and Rockland, New York.

FIRM LOCATIONS
55 Northern Boulevard, Suite 302, Great Neck, NY 11021

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