Property Claim

Licciardi Law Office

Hurricane Damage Information Intake
Potential Client Intake Form

Kindly complete this form and click the SUBMIT button at the bottom. Thank you. This form is for information gathering purposes only and is not a legal engagement of Licciardi Law Office. The information will be reviewed and someone will get back to you. This is not an engagement of services. Information provided is only for evaluation purposes. If you do not hear from us withing 24 hours your form may not have been submitted properly, call us at (504) 279-1000 if you do not hear from us.
Client Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address of the effected property*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Email
example@example.com
What is the name of your Insurance Company?
What id your Policy Number?
Please provide any pictures of damage as a result of the storm.

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If you have any photos from before the damage occurred please provide them here.

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**Please feel free to share with us any other details you would like us to know so that we can best serve your needs. Including current housing arrangements and if applicable custody arrangements.
Thank you for completing this form. Please click on the SUBMIT button below. We will be in touch with you within 24 hours.
Date Submitted

MonthDayYear
Date
Should be Empty:

Licciardi Law Office