Invoice NCJUA 09/05/19 – SWA Claims Management Services LLC

Claim Number*
Policy Number*
Date of Loss*
Storm NO / CAT NO
Adjuster Name*
Adjuster Number*
Insured Name*
Type of claim*
Risk Location*
City*
State*
Zip Code*
Is this a supplement?*
Supplements are created when additional work was performed on the file and needs additional billing.
- Yes
- No
Is this a revision?*
Revisions are created when the original invoice was incorrect/rejected and needs modifications.
- Yes
- No

Service Fee
Erroneous/Withdrawn Assignment?*
- Yes
- No
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# Cancelled Claim
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Hidden - Total Cancelled Claim
Closed without payment?*
- Yes
- No
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# Closed without payment
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Hidden - Total Closed without payment

GAL*
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
GAL Schedule Billing
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Hidden - Service Fee based on GAL
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Hidden - Total Service Fee
Time & Expense
Field Adjuster Hours*
Time & Expense Total
× Please verify policy limits: cannot bill over policy limits! Time and Expense Billing for Losses that Exceed $250,001.00 with a Minimum Billing of $6325.00

Supplement
Original GAL*
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
Original Service Fee
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Hidden - Service Fee based on Original GAL
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NEW
New GAL*
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
New Service Fee
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Hidden - Service Fee Based on New GAL
This field is hidden when viewing the form
Hidden - Supplemental Billing Positive
Supplemental Billing
Supplemental Billing

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