Mortgage Claim

Please complete the form in full providing all necessary information. Thank you.

USE THE TAB KEY TO MOVE BETWEEN FIELDS

General Information:
Today's Date:
Your Name:*
Your Financial Institution: *
Your telephone number including area code: *
Your Email Address: *

Borrower Information:
Borrower Name(s): *
Borrower Street Address: *
Borrower City: *
Borrower State: *
Borrower Zip Code: *
Borrower's Daytime Telephone Number: *
Borrower's Loan Number:

Loss Location Information:
Location of Loss Address (if different from above):
Loss Location City:
Loss Location State:
Loss Location Zip Code:

Loss Information:

Type of Loss (put YES in proper box):
Borrower:	Foreclosure:

Foreclosure fees included?:	If yes, amount:
Date of Loss: *
Please enter details of loss (be specific): *
Please enter areas of damage (be specific) *

Payment Information:
Loan Balance: *
Payoff: *
Number of payments past due: *
Next Due Date: *

Please submit the following information FOR ALL CLAIM TYPES:

Claim Form
Copy of Security Agreement
Copy of Deed
Copy of Payment History (entire history) indicating current balance and next due date
Copy of Affidavit of Foreclosure
Foreclosure Expense Bills
Copy of Fire Report (required, if applicable)
Copy of Police Report (required, if applicable)

Once you have submitted this claim form online by clicking the SUBMIT button below, please also submit all required documents to:

Evans, Simpson & Associates, Inc.
PO Box 1549
Snellville, GA 30078
Email: claims@evans-simpson.com
Fax: 770-982-1418
Phone: 800-635-5142

Before submitting this form, please take a moment to review the information you've provided for accuracy.