New Client Intake Form
Client Details:
Contact Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Phone Number
*
Format: (000) 000-0000.
E-mail Address
*
This is the email that will receive all communications.
Named Insured on Policy
First Name
Last Name
Is the claim address different than contact's address?
*
Yes
No
Property Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Peril:
*
ie: wind, hail, fire, flood, etc.
Date of Loss:
*
Time of Loss
Insurance Details:
Insurance Company
*
Insurance Policy Number
*
Insurance Claim Number
*
Claim Adjuster Name
Claim Adjuster Email
Claim Adjuster Phone
Working with a contractor? Please list their name.
Would you like a Contract prepared?
Yes
No, I will let the office staff know when I am ready for the Contract.
Would you prefer to E-Sign the contract?
Yes, Please send me an e-sign link.
No, please send me a PDF I can print and sign, then return.
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