CLAIM REVIEW
FL Public Adjusting Firm License: W906657
POLICYHOLDER INFORMATION
Policyholder Owner Information
*
Owned by Individual Person
Owned by an entity or company
Policyholder Name
*
First Name
Last Name
Is there a second policyholder named on the policy?
*
Please Select
Yes
No
Secondary Policyholder Name
First Name
Last Name
Entity Name
CLAIM INFORMATION
Location of Property
*
Insurance Company
*
Policy Number
*
Claim Number
Date of Loss
*
/
Month
/
Day
Year
The date the damage happened
Cause of damage
*
Please Select
Hurricane
Storm
Need Advice
Has the insurance company made any payments?
*
Please Select
Yes
No
Have you had prior claims at this property?
*
Please Select
Yes
No
Description of the damage
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Choose a file
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CONTACT INFORMATION
Contact Person
First Name
Last Name
Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
Mailing Address (if different than the location of the damaged property)
Referred by
Who, if anyone, referred you to Covered Loss?
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Should be Empty: