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6785 Telegraph Road, Suite 400
Bloomfield Hills, MI 48301
(877) 454-3400

Claim Referral

Conveniently refer Claim Information to Latitude Subrogation Services.

// Main Information

Company

Address (Line 1)

Address (Line 2)

City

State or Providence

Postal Code

Phone

Fax

Claim Representative

Claim Number

// Insured Party

Company

Address (Line 1)

Address (Line 2)

City

State or Providence

Postal Code

Phone

DOB

// Insured Owner

Company

Address (Line 1)

Address (Line 2)

City

State or Providence

Postal Code

Phone

DOB

// Insured's Vehicle

Make

Model

Year

Vehicle #

VIN/HIN

Driver

Date of Loss

State or Providence of Loss

Description

// Adverse Party

Company

Address (Line 1)

Address (Line 2)

City

State or Providence

Postal Code

Phone

DOB

DL #

SSN/SIN

// Adverse Owner

Company

Address (Line 1)

Address (Line 2)

City

State or Providence

Postal Code

Phone

DOB

DL #

SSN/SIN

// Police Report

Taken?

Department

Report Number

Last Amount Paid

Last Date Paid

// Financial Information

Collision Damage

Personal Injury

UMBI

Insured's Deductible

Other (Desc/Amount)

Total

// Miscellaneous

Comments

Confirmation Email

// Supporting Documentation

Attach Files (Optional)

Step 1	Step 2

Files Attached:

Submit

We provide comprehensive recovery services as a national leader in subrogation outsourcing.

We provide companies the opportunity to liquidate their recovery assets without incurring the costs associated with collection or the risk.

// Corporate Affiliates

National Association of Subrogation Professionals

// Social Media

6785 Telegraph Road, Suite 400
Bloomfield Hills, MI 48301
(877) 454-3400