Claim Evaluation Request Form
Please fill this out if you have an open or existing claim that you would like us to review to determine if we can assist. Most of the information requested below can be found on the estimate provided by your insurance carrier.
Full Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Briefly describe why you would like us to review your claim, examples: (Denied claim, underpaid/improper settlement, carrier denied damage):
Have you mitigated the damage? (For example, did you have anyone prevent further damage using tarps, drying equipment, etc.?)
Yes
No
Please upload all documents related to the claim, such as denial letters, estimates from both the insurance carrier and contractor, and any written communications or letters from the carrier.
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Claim Number:
Policy Number:
Date of loss:
-
Month
-
Day
Year
Date
Insurance Carrier:
Peril or Cause of Loss:
Hail
Wind
Fire
Water
Pipe Freeze
Tornado
Ice
Other
Contractor Information
Please provide this information if you are either a contractor submitting this as a referral or a client with a contractor performing the work.
Contractor's Name (Point of contact)
First Name
Last Name
Name of contractor's company
Contractor's Phone Number (Point of contact)
Contractor's Email (Point of contact)
Company Cam or Other Photo Software Link: This is required for all contractor referrals
****Please, Double Check That You've Uploaded All Relevant Information***
*
Did you upload all documents associated to the claim? Like ITELS/NTS reports, claim communications, denial letters, repair documentation, carrier estimates?
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