The DAMEX Corporation ~ State Certified General Contractor serving Southwest Florida since 1981 ~ Insurance Agents & Adjusters Page ~ Assignment Form

24 HOUR EMERGENCY RESPONSE SERVICE

      * Introduction
      * Explanation Of Services
      * How DAMEX Can Help
      * Contact Us
      * Assignment Form

The Damex Corporation is a State Certified General Contractor of Southwest Florida, offering - A full 24 hour emergency service, insurance claims and restoration for most all of your needs, including water, fire, mold and storm damages etc., residential and commercial remodeling. 800-226-4060 / 941-624-3100 in Port Charlotte, Florida or 239-542-1000 in Cape Coral, Florida

Insurance Agents & Adjusters
~ Assignment Form ~

You can assign losses to us online by using our simple, yet comprehensive Assignment Form below. Our form is a safe and secure way of transferring your sensitive information to us. After you submit the form, it will be sent to us via encrypted email. An estimator will then be assigned and they will contact you A.S.A.P..

If you prefer to print the form out and fax it, you can download a Acrobat PDF file here or download a Word document here if you would like to fill out and fax
or email from your computer. Instructions for emailing, faxing or sending the form via standard mail are included in the Word document.

Type of Loss

Please choose one (required)

*NOTE

for Emergency Services it's best to phone us at; 1-800-226-4060

Type of Loss

Date of Loss //

Your Information

Please fill in this section, so that we may contact you with information about the loss. Note that items in red are required.

First Name		Last Name
Claim/File Number
Insurance Company
Address
City		State
Zip Code
Email
Area Code & Phone		Ext. #
Fax
Check to receive acknowledgement of this assignment.
Check to have our initial report faxed to you.
Check to have our initial report emailed to you

Insured's Information

Please fill in this section, so that we may process your claim efficiently. Note that items in red are required.

Insured's First Name		Last Name
Address of Loss
City		State
Zip Code
Insured's Address
City		State
Zip Code
Insured's Phone		Work Phone
Contact First Name		Last Name
Contact Phone		Other Phone
Comments

Two Offices to Serve You .....
	17436 Seymour Ave. Port Charlotte, FL 33953 941-624-3100 941-624-5032 fax	&	1708 S.E. 47th Street Cape Coral, FL 33904 239-542-1000 239-549-7588 fax

1-800-226-4060

Company Facts - Emergency Services - Home Owners
Insurance Agents & Adjusters - Opening Page

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