Loss Control Inspection Request Form

INSURANCE COMPANY NAME:*

RTS ACCOUNT #:*

REQUESTOR'S NAME:*

 

POLICY #1:*

POLICY #2:

 

INSURED OR BUSINESS NAME:*

STREET ADDRESS:

 

CITY:

STATE:

ZIP CODE:

 

Check this box if Survey Address and Insured's Street Address are the same.

 

SURVEY ADDRESS:

CITY:

STATE:

ZIP CODE:

 

**Coverage not available in all areas.

 
 

CONTACT'S NAME:

CONTACT'S PHONE:

TYPE?:

 

CONTACT'S EMAIL:

 
 

ORDER DATE:

AGENT / AGENCY NAME:

TELEPHONE #:

 
POLICY AMOUNT:
 

PROP. $:

LIAB. $:

 
POLICY COVERAGE TYPE / BUSINESS TYPE / WORK PERFORMED:

-Please specify the Type of Operation found at this location.

INSURANCE BROKER: Insurance Company (Carrier):

 
 

SPECIAL ATTENTION / ADDITIONAL COMMENTS:

 
PHOTOS:
  • Front

  • Rear

  • Other

PHONE SURVEY:
  • Phone Survey Only

ADD REPLACEMENT COST:
  • Replacement Cost

 
 

FULL SURVEY REPORTS:

AUTOMOBILE / GARAGE:

 

PRODUCT SURVEYS:

SUPPLEMENTS:

 
SPECIFIED REPORTS
 

Multiperil (MP) & Property Only (PO):

LIABILITY SURVEYS:

 

SMALL BUSINESS REPORTS:

CLIENT SPECIAL:

 
 

You can PRINT the request AFTER submission.

A four-digit RTS Account # is required (EX: 1005).

Please BOOKMARK this page for future reference.

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Fields marked with asterisk * are required.

You must click SUBMIT to send the request.

AFTER submitting the request, you will have the option to PRINT the page for your records.

Our staff covers many areas in the Southeastern US.   Please contact RTS for more details.

**Coverage is not available in all areas.

***Special Fees apply for Outer Banks region.