Claim Intake Form
Please fill in as much of the information as possible so that we can provide an estimate as accurately and efficiently as possible.
Client Information
Job #
Client Name
*
First Name
Last Name
Company Name (if applicable)
Client Email
*
example@example.com
Client Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Claim Information
What service do you need us to perform?
*
Emergency Cabinet Removal (Disaster Restoration)
Cabinet Restoration (Disaster Restoration)
Commercial Furniture & Millwork Repair (Commercial)
Residential Furniture Repair (Residential)
Please explain the damage as clearly as possible
*
Which parties are involved in restoring the impacted area? (Select all that apply)
*
Insurance Company
Mitigation Company
General Contractor
Other
Who should we send the estimate to?
*
Client / Homeowner
Insurance Company
Mitigation Company
General Contractor
Other
Insurance Company Information
Insurance Company
Please Select
AAA
Allstate
Ameriprise
California Casualty
Century National
Chubb
CIG
CNA
Code Blue
CSAA
CSE
Encompass
Farmers
Fireman's Fund
First American
Hartford
Hippo
Homesite
Horace Mann
Lemonade
Liberty Mutual
Mercury
Met Life
Nationwide
Pacific Specialty Insurance
Progressive
Safeco
State Farm
Stillwater
Tower Select
Travelers
Unigard
Universal North America
USAA
OTHER (Please List Below)
If Other, please list company name:
Claim #
Adjuster's Name
First Name
Last Name
Adjuster's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Adjuster's Email
example@example.com
Mitigation Company Information
Mitigation Company
Mitigation Company Contact Person
First Name
Last Name
Mitigation Company Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mitigation Company Contact Email
example@example.com
General Contractor Information
General Contractor Company
General Contractor Contact Person Name
First Name
Last Name
General Contractor Contact Person Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
General Contractor Contact Person Email
example@example.com
Other Party Information
Other Party Company
Other Party Contact Person Name
First Name
Last Name
Other Party Contact Person Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Party Contact Person Email
example@example.com
Emergency Cabinet Removal (Disaster Restoration)
What needs to be removed?
Rows
Needs to be removed?
How many cabinets?
How many linear feet?
Full height cabinets
Upper cabinets
Lower cabinets
Cabinets below kitchen island
Other
Is the site asbestos- and lead-free?
Yes
No
Not Applicable (no abatement necessary)
If no, are you working with someone to clear the impacted area of asbestos and lead?
Yes
No
If no, when is abatement scheduled to be completed?
Have you (i.e. the insured) lost functional use of your kitchen / home?
Yes
No
Please provide photo(s) of the overall kitchen (inclusive of all 4 corners of the kitchen)
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of
Please provide photo(s) of the damaged cabinets (cabinets that need to be removed), 3-4 feet away
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Choose a file
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of
If possible, please provide a mitigation report so we can assess the extent of the damage.
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of
Has the mitigation been completed?
Yes
No
Not Applicable (no mitigation necessary)
Do you or the mitigation company need access to the floors?
Yes
No
Do you or the mitigation company need access to the walls?
Yes
No
Do any of the following appliances need to be removed? (Select all that apply)
Refrigerator
Refrigerator (Sub-Zero Technology)
Range
Sink
Dishwasher
Double Oven
Other
Source of Damage (Select all that apply)
Dishwasher
Refrigerator
Water Supply Line
Waste Line
Fire
Under Slab Leak
Other
Are the cabinets packed out?
Yes
No
Cabinet Restoration (Disaster Restoration)
Have the damaged cabinets already been removed?
*
Yes
No
Are you looking for us to conduct an on-site inspection?
*
Yes
No
Have you (i.e. the insured) lost functional use of your kitchen / home?
Yes
No
What area(s) of the home have been impacted? (Select all that apply)
Kitchen
Living room
Dining room
Laundry room
Bedroom(s) (upper floor)
Bedroom(s) (lower floor)
Other
Has the mitigation been completed?
Yes
No
Not Applicable (no mitigation necessary)
Have the toe kicks and toe skins been removed?
Yes
No
Unsure
Please provide photo(s) of the damaged cabinets - straight on, 3-4 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide photo(s) of any damages (e.g., splintering, cracks, separations, swelling, distortion) - straight on, 1-2 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Commercial Furniture & Millwork Repair (Commercial)
Does the repair required encompass anything beyond wood repair (e.g., metal, stone, plastic, wickers, etc.)?
*
Yes
No
If yes, what repairs are required beyond wood repair?
*
Is there anything else that you think we should know about the damage or scope of work?
Please provide photo(s) of the damaged area - straight on, 3-4 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide photo(s) of any damages (e.g., splintering, cracks, separations, swelling, distortion) - straight on, 1-2 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide any additional photo(s) of the damaged area
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Residential Furniture Repair (Residential)
Does the repair required encompass anything beyond wood repair (e.g., metal, stone, plastic, wickers, etc.)?
*
Yes
No
If yes, what repairs are required beyond wood repair?
*
Is there anything else that you think we should know about the damage or scope of work?
Please provide photo(s) of the damaged area - straight on, 3-4 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide photo(s) of any damages (e.g., splintering, cracks, separations, swelling, distortion) - straight on, 1-2 feet away
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide any additional photo(s) of the damaged area
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Billing Information
Who will be financially responsible for paying Furniture Medic On Call?
*
Client
Insurance Company
Mitigation Company
General Contractor
Other
Is the person handling billing the same as the person listed as the Client?
*
Yes
No
Billing Contact Name
*
First Name
Last Name
Billing Contact Email
*
example@example.com
Billing Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the billing address the same as the service address?
Yes
No
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
On-Site Information
What parking is available for our technicians?
Driveway
Street Parking (Paid)
Street Parking (Unpaid)
Other
Does the work area have the following items for our technicians to utilize? (Select all that apply)
Electrical outlet(s)
Lighting
On-site restroom
Outside work space (covered area with 6' radius around the work space)
How will our technicians access the site?
Client will meet Technician(s)
Other Party (e.g., tenant) will meet Technician(s)
Lockbox
Other
Are there any animals on site?
Yes
No
If yes, what sort of animal?
Are there any animals on site?
Yes
No
Other Party Name
First Name
Last Name
Other Party Email
example@example.com
Other Party Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Lockbox Location
Lockbox Code
We bring the damaged cabinets back to our warehouse for storage prior to repairs. Do you have any objections to that?
Yes
No
Where would you prefer us to store the salvageable cabinet materials?
Bedroom (Lower Floor)
Bedroom (Upper Flower)
Dining Room
Garage
Kitchen
Living Room
Outdoors
Work Location
On-Site
Shop
Who is transporting the work to the shop?
Us (Internally)
Moving Company
Name of Moving Company
Moving Company Point of Contact Name
First Name
Last Name
Moving Company Point of Contact Email
example@example.com
Moving Company Point of Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Information
How did you hear about Furniture Medic On Call?
*
Insurance Company
Mitigation Company
General Contractor
Google
Yelp
Other
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