Make A Claim Insured Organization*Street Address 1*Street Address 2City*State*Zip*Claimant Name*Phone*Email*Contact Name*Contact Phone*Contact Email*Comments/QuestionsDate of Loss* Date Format: MM slash DD slash YYYY Description of Loss*Has a lawsuit been filed?*YesNoDate Served* Date Format: MM slash DD slash YYYY Attachments Specialized Risk Management for Staffing Agencies 5800 South Eastern Ave Suite 400 Los Angeles, CA 90040 Tel (323) 400-6705 CA License # 0747420