Intake Sheet
Please provide the following information to the best of your ability so we can assist you with your loss.
Name
First Name
Last Name
Email
example@example.com
Phone number
Format: (000) 000-0000.
Marital Status
Married
Single
Spouses Name
First Name
Last Name
How did you hear about us?
Please Select
search engines (Google, Bing, etc,)
social media (Facebook, LinkedIn, etc.)
former client
community forum
other
Were you referred by someone? If so, please list their name below.
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Please upload a picture of your license for verification purposes.
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Information regarding your loss
Date of loss
/
Month
/
Day
Year
Date
Address of the damaged property (if different from your home)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did the loss occur?
Specifically, where are the damages to your property?
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Information regarding the damage property
What year did you purchase the property?
Do you currently have a mortgage for the property?
Yes
No
Please provide the name of the mortgage company.
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Are you currently living in the damaged property?
Yes
No
If no, please click to provide the address where you are living currently
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Personal Property Damage
(i.e couches, TV, personal belongings.
Did you suffer any personal property damage as a result of your loss? (i.e. clothes, electronics ect)
Yes
No
If yes, please describe the personal property damaged below.
Please describe, the personal property that has been damaged
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Was anyone else residing in the property with you at the time of loss?
Yes
No
If yes, please provide their information below.
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
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Were there any children residing in the damage property at the time of loss?
Yes
No
If yes, please provide their information below.
Child #1
First Name
Last Name
Child #2
First Name
Last Name
Child #3
First Name
Last Name
Child #4
First Name
Last Name
Child #5
First Name
Last Name
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Photographs of the damage
Do you have any photographs or videos of the damage to your property?
Yes
No
If so, please upload photographs of the damage below
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Repairs
Did you make any repairs after the loss occurred?
Yes
No
If yes, what repairs were made?
Did you contact any contractors to make any repairs to your property?
Yes
No
If yes, please provide their information below.
Contractor #1
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Contractor #2
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contractor #3
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insurance Information
Who is your current Insurance Carrier?
Did you report your loss to your insurance company?
Yes
No
When did you report the loss to the insurance carrier?
-
Month
-
Day
Year
Date
What is the claim number regarding your reported claim.
What was the result of you reporting a claim to the insurance company?
Upload specific insurance documents such as insurance policy, claim's determination, correspondence from carrier, etc.
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Copy of your Insurance Policy
Do you have a digital copy of your policy? (i.e, PDF, word)
Yes
No
If yes, please feel free to upload a copy of a policy.
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Flood Insurance
Do you have Flood insurance?
Yes
No
If you answer "YES" Please click below.
If yes, what is the name of your Flood Insurance Company?
Did you report the loss to your Flood insurance provider?
Yes
No
If yes, please feel free to upload a copy of a policy.
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Public Adjuster Information
Did you retain a Public Adjuster in regards to your loss?
Yes
No
If yes, please provide their information below.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Water Mitigation Company
Did you retain a water mitigation company in regards to your loss?
Yes
No
If yes, please provide their information below.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Background information
Have you filed a claim with an insurance company before? If so, please list the year, the description of the claim and the resolution.
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Is there any other additional information you would like to provide regarding your loss?
Additional information
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