Client Intake Form
Client Information
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Work Number
-
Area Code
Phone Number
Cell Number
-
Area Code
Phone Number
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Additional Contacts
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Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Relation
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Job Information
Type of Damage
*
Please Select
Water
Mold
Fire
Storm
Remodel
Other
Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Job Description:
*
Year built:
Is this an ongoing issue?
Yes
No
Number of affected rooms
How many floors (stories) affected?
Is there any ceiling damage?
Yes
No
Has drywall debris come down and landed on the floor or content?
Yes
No
If yes, what was affected?
Does your home have a basement, crawlspace, both?
Basement
Crawlspace
Neither
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Job Information Cont
Is there currently any standing water?
Yes
No
What types of flooring have been affected throughout your home?
Carpet
Tile
Laminate
Hardwood
Vinyl
Concrete
Other
Does any furniture or personal belongings need to be moved to remove affected flooring or carpet pad?
Yes
No
Have any of your personal belongings been damaged from the water?
Yes
No
Does the current situation warrant an emergency response? Or would you like to schedule for an inspection at a later date?
Emergency
Inspection
Preferred Inspection Date and Time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Weekly Availability for On-site Work & Special Instructions
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Insurance Information
Insurance Company
Policy Number
Claim Number
Adjuster's Name
Adjuster's Email
Adjuster's Phone
Referred by:
Name of Apex Sales Representative
*
Submit
Should be Empty: