Make A Claim Insured Organization* Street Address 1* Street Address 2 City* State* Zip* Claimant Name* Phone* Email* Contact Name* Contact Phone* Contact Email* Comments/QuestionsDate of Loss* MM slash DD slash YYYY Description of Loss*Has a lawsuit been filed?* Yes No Date Served* MM slash DD slash YYYY AttachmentsMax. file size: 256 MB. Δ Specialized Risk Management for Staffing Agencies 5800 South Eastern Ave Suite 400 Los Angeles, CA 90040 Tel (323) 400-6705 CA License # 0747420