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General Placement Form 


Submitting a general placement form for a claim through the website is no longer active. 


Please submit claims directly through our e-mail address at Info@sampliner.com


Client’s who have access to the portal also have an option to submit claims through the portal. 





Phone: 212-239-4888

Fax:     212-239-4898

Address: 505 Eighth Avenue New York, NY 10018




Submit A Claim
Please use this form to submit a claim to S.S. Sampliner & Co., Inc.

When complete, you may submit your claim directly to our Web site or print the form and fax it to us at:     (001) 1-212-239-4898.

For further assistance please call us at:

(001) 1-212-239-4888

Upload A File
You may attach additional supporting documents. Accepted file formats include:

Comma Delimited


Mail A Claim
You may print this form and submit your claim by mail to:

S.S. Sampliner & Co., Inc.
505 Eighth Avenue
New York, NY 10018

Please include any supporting documentation with your claim.



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