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Submission: On August 15 via api from US — Scanned from DE
Submission: On August 15 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
GET https://www.romvalleycg.com/
<form role="search" method="get" action="https://www.romvalleycg.com/">
<input class="search-form_it js--focus-me" type="search" value="" name="s" placeholder="Search" size="40"><button class="search-form_button" type="submit" value="Search"><span class="icon-search search-form_button-ic"></span><span
class="search-form_button-tx">Search</span></button>
</form>POST /submit-assignment/?wpforms_form_id=11604
<form id="wpforms-form-11604" class="wpforms-validate wpforms-form wpforms-ajax-form" data-formid="11604" method="post" enctype="multipart/form-data" action="/submit-assignment/?wpforms_form_id=11604" data-token="ac4cca4a772b5098d2c863093109ab92"
novalidate="novalidate"><noscript class="wpforms-error-noscript">Please enable JavaScript in your browser to complete this form.</noscript>
<div class="wpforms-field-container">
<div id="wpforms-11604-field_1-container" class="wpforms-field wpforms-field-text" data-field-id="1"><label class="wpforms-field-label" for="wpforms-11604-field_1">Insurance Company <span class="wpforms-required-label">*</span></label><input
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<div id="wpforms-11604-field_6-container" class="wpforms-field wpforms-field-text" data-field-id="6"><label class="wpforms-field-label" for="wpforms-11604-field_6">Street Address <span class="wpforms-required-label">*</span></label><input
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<div id="wpforms-11604-field_7-container" class="wpforms-field wpforms-field-text" data-field-id="7"><label class="wpforms-field-label" for="wpforms-11604-field_7">Address Line 2</label><input type="text" id="wpforms-11604-field_7"
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<div id="wpforms-11604-field_8-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="8"><label class="wpforms-field-label" for="wpforms-11604-field_8">City <span
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<div id="wpforms-11604-field_9-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="9"><label class="wpforms-field-label" for="wpforms-11604-field_9">State <span class="wpforms-required-label">*</span></label><input
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<div id="wpforms-11604-field_11-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="11"><label class="wpforms-field-label" for="wpforms-11604-field_11">Postal / Zip Code <span
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<div id="wpforms-11604-field_12-container" class="wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-classic" data-field-id="12"><label class="wpforms-field-label" for="wpforms-11604-field_12">Country <span
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<div id="wpforms-11604-field_13-container" class="wpforms-field wpforms-field-text" data-field-id="13"><label class="wpforms-field-label" for="wpforms-11604-field_13">Adjuster Name <span class="wpforms-required-label">*</span></label><input
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<div id="wpforms-11604-field_14-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="14"><label class="wpforms-field-label" for="wpforms-11604-field_14">Adjuster Email Address <span
class="wpforms-required-label">*</span></label><input type="text" id="wpforms-11604-field_14" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][14]" required=""></div>
<div id="wpforms-11604-field_15-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="15"><label class="wpforms-field-label" for="wpforms-11604-field_15">Adjuster Phone <span
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<div id="wpforms-11604-field_16-container" class="wpforms-field wpforms-field-divider" data-field-id="16"></div>
<div id="wpforms-11604-field_40-container" class="wpforms-field wpforms-field-html" data-field-id="40">
<div id="wpforms-11604-field_40">Please enter the claim number, claim amount in dollars, date of loss, type of damage, liability accepted, and subrogation for faster processing.</div>
</div>
<div id="wpforms-11604-field_18-container" class="wpforms-field wpforms-field-text" data-field-id="18"><label class="wpforms-field-label" for="wpforms-11604-field_18">Claim Number <span class="wpforms-required-label">*</span></label><input
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<div id="wpforms-11604-field_19-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="19"><label class="wpforms-field-label" for="wpforms-11604-field_19">Claim Amount in Dollars <span
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<div id="wpforms-11604-field_17-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="17"><label class="wpforms-field-label" for="wpforms-11604-field_17">Date of Loss <span
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<div id="wpforms-11604-field_22-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="22"><label class="wpforms-field-label" for="wpforms-11604-field_22">Type of Damage</label><input type="text"
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<div id="wpforms-11604-field_20-container" class="wpforms-field wpforms-field-select wpforms-one-half wpforms-field-select-style-classic" data-field-id="20"><label class="wpforms-field-label" for="wpforms-11604-field_20">Liability Accepted? <span
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<option value="Yes">Yes</option>
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<div id="wpforms-11604-field_21-container" class="wpforms-field wpforms-field-select wpforms-one-half wpforms-first wpforms-field-select-style-classic" data-field-id="21"><label class="wpforms-field-label"
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<option value="No">No</option>
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<div id="wpforms-11604-field_23-container" class="wpforms-field wpforms-field-divider" data-field-id="23"></div>
<div id="wpforms-11604-field_25-container" class="wpforms-field wpforms-field-text" data-field-id="25"><label class="wpforms-field-label" for="wpforms-11604-field_25">Insured Name / Company <span
class="wpforms-required-label">*</span></label><input type="text" id="wpforms-11604-field_25" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][25]" required=""></div>
<div id="wpforms-11604-field_26-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="26"><label class="wpforms-field-label" for="wpforms-11604-field_26">Insured Phone Number</label><input type="text"
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<div id="wpforms-11604-field_24-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="24"><label class="wpforms-field-label" for="wpforms-11604-field_24">Policy Amount in Dollars</label><input type="text"
id="wpforms-11604-field_24" class="wpforms-field-large" name="wpforms[fields][24]"></div>
<div id="wpforms-11604-field_27-container" class="wpforms-field wpforms-field-checkbox wpforms-list-inline" data-field-id="27"><label class="wpforms-field-label" for="wpforms-11604-field_27">RCV/ACV?</label>
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<li class="choice-4 depth-1"><input type="checkbox" id="wpforms-11604-field_27_4" name="wpforms[fields][27][]" value="No"><label class="wpforms-field-label-inline" for="wpforms-11604-field_27_4">No</label></li>
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</div>
<div id="wpforms-11604-field_28-container" class="wpforms-field wpforms-field-divider" data-field-id="28"></div>
<div id="wpforms-11604-field_30-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="30"><label class="wpforms-field-label" for="wpforms-11604-field_30">Claimant Name <span
class="wpforms-required-label">*</span></label><input type="text" id="wpforms-11604-field_30" class="wpforms-field-large wpforms-field-required" name="wpforms[fields][30]" required=""></div>
<div id="wpforms-11604-field_31-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="31"><label class="wpforms-field-label" for="wpforms-11604-field_31">Claimant Contact</label><input type="text"
id="wpforms-11604-field_31" class="wpforms-field-large" name="wpforms[fields][31]"></div>
<div id="wpforms-11604-field_33-container" class="wpforms-field wpforms-field-text wpforms-one-half wpforms-first" data-field-id="33"><label class="wpforms-field-label" for="wpforms-11604-field_33">Claimant Phone Number</label><input type="text"
id="wpforms-11604-field_33" class="wpforms-field-large" name="wpforms[fields][33]"></div>
<div id="wpforms-11604-field_34-container" class="wpforms-field wpforms-field-text wpforms-one-half" data-field-id="34"><label class="wpforms-field-label" for="wpforms-11604-field_34">Claimant Email</label><input type="text"
id="wpforms-11604-field_34" class="wpforms-field-large" name="wpforms[fields][34]"></div>
<div id="wpforms-11604-field_35-container" class="wpforms-field wpforms-field-divider" data-field-id="35"></div>
<div id="wpforms-11604-field_42-container" class="wpforms-field wpforms-field-text" data-field-id="42"><label class="wpforms-field-label" for="wpforms-11604-field_42">Promo Code</label><input type="text" id="wpforms-11604-field_42"
class="wpforms-field-medium" name="wpforms[fields][42]"></div>
<div id="wpforms-11604-field_36-container" class="wpforms-field wpforms-field-checkbox wpforms-list-inline" data-field-id="36"><label class="wpforms-field-label" for="wpforms-11604-field_36">Requested Service</label>
<ul id="wpforms-11604-field_36">
<li class="choice-1 depth-1"><input type="checkbox" id="wpforms-11604-field_36_1" name="wpforms[fields][36][]" value="Settlement Negotiations"><label class="wpforms-field-label-inline" for="wpforms-11604-field_36_1">Settlement
Negotiations</label></li>
<li class="choice-2 depth-1"><input type="checkbox" id="wpforms-11604-field_36_2" name="wpforms[fields][36][]" value="Audit Report Only"><label class="wpforms-field-label-inline" for="wpforms-11604-field_36_2">Audit Report Only</label></li>
<li class="choice-3 depth-1"><input type="checkbox" id="wpforms-11604-field_36_3" name="wpforms[fields][36][]" value="Rush Close (Add $150.00)"><label class="wpforms-field-label-inline" for="wpforms-11604-field_36_3">Rush Close (Add
$150.00)</label></li>
</ul>
</div>
<div id="wpforms-11604-field_37-container" class="wpforms-field wpforms-field-file-upload" data-field-id="37"><label class="wpforms-field-label" for="wpforms-11604-field_37">File Upload</label>
<div class="wpforms-uploader dz-clickable" data-field-id="37" data-form-id="11604" data-input-name="wpforms_11604_37" data-extensions="png,jpeg,jpg,docx,doc,pdf,xlsx,xls,ppt,pptx" data-max-size="104857600" data-max-file-number="10"
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<span class="modern-title">Click or drag files to this area to upload.</span>
<span class="modern-hint">You can upload up to 10 files.</span>
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<div class="wpforms-field wpforms-field-hp"><label for="wpforms-11604-field-hp" class="wpforms-field-label">Comment</label><input type="text" name="wpforms[hp]" id="wpforms-11604-field-hp" class="wpforms-field-medium"></div>
<div class="wpforms-submit-container"><input type="hidden" name="wpforms[id]" value="11604"><input type="hidden" name="wpforms[author]" value="1"><input type="hidden" name="wpforms[post_id]" value="11539"><button type="submit"
name="wpforms[submit]" id="wpforms-submit-11604" class="wpforms-submit highlightsubmitbutton" data-alt-text="Sending..." data-submit-text="Submit Assignment" aria-live="assertive" value="wpforms-submit">Submit Assignment</button><img
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</form>Text Content
(317) 416-1223 * Contact Us Search * Home * About * Services * Loss Expertise * ROI Guarantee * Liability Education * Submit Assignment * RVCG Journal * Home * About * Services * Loss Expertise * ROI Guarantee * Liability Education * Submit Assignment * RVCG Journal SUBMIT ASSIGNMENT SUBMIT ASSIGNMENT Please enable JavaScript in your browser to complete this form. Insurance Company * Street Address * Address Line 2 City * State * Postal / Zip Code * Country *United States Adjuster Name * Adjuster Email Address * Adjuster Phone * Please enter the claim number, claim amount in dollars, date of loss, type of damage, liability accepted, and subrogation for faster processing. Claim Number * Claim Amount in Dollars * Date of Loss * Type of Damage Liability Accepted? *YesNo Subrogation?YesNo Insured Name / Company * Insured Phone Number Policy Amount in Dollars RCV/ACV? * Yes * No Claimant Name * Claimant Contact Claimant Phone Number Claimant Email Promo Code Requested Service * Settlement Negotiations * Audit Report Only * Rush Close (Add $150.00) File Upload Click or drag files to this area to upload. You can upload up to 10 files. Accepted files: png, jpg, pdf, pptx and xlsx. Comment Submit Assignment ROM Valley CG exists to solve the critical issues facing our clients, both large and small. PAGES * Home * About * Contact Us * Submit Assignment * Services * Loss Expertise * ROI Guarantee * Liability Education * RVCG Journal All rights reserved.