Mortgage Claim

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

USE THE TAB KEY TO MOVE BETWEEN FIELDS

Claim Information Details:

Today's Date:

Your Name:

Your Financial Institution:

What is your telephone number:

What is your email address:

Borrower Name(s):

Borrower Street Address:

Borrower City:

Borrower State:

Borrower Zip Code:

Location of Loss Address (if different from above):

Loss Location City:

Loss Location State:

Loss Location Zip Code:

The borrower's work telephone number:

The borrower's home telephone number:

Borrower's Loan Number:

Policy Number:

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

Foreclosure fees included?:     If yes, amount: 

Date of Loss:

Number of Payments Past Due:

Next Due Date:

Balance:

Payoff:

Please enter details of loss (be specific):

Please enter areas of damage (be specific):

Please submit the following information FOR ALL CLAIM TYPES:

1. Claim Form
2. Copy of Security Agreement
3. Copy of Deed
4. Copy of Payment History (entire history) indicating current balance and next due date
5. Copy of Affidavit of Foreclosure
6. Foreclosure Expense Bills
7. Copy of Fire Report (required, if applicable)
8. 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: 770-979-3173
Phone: 770-979-1354

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