This intake form is intended to be completed by the Policyholder only. If you are a contractor or any other party referring a Policyholder to Catastrophic Claim Legal Group, do not fill out this form.
Policyholder Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Contact Method
*
Emails
Calls
Texts
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Is your damaged property at the same address as your mailing address you provided?
*
Yes
No
Insurance Information
Insurance Carrier
*
Insurance Policy Number
*
Have you already contacted your insurance carrier and filed a claim?
*
Yes
No
Insurance Claim Number
Insurance Adjuster
First Name
Last Name
Adjuster Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Adjuster Email
example@example.com
Contractor Information
Are you working with a contractor regarding your property damage claim?
*
Yes
No
Contractor Company
The company name of the contractor you're working with.
Contractor Name
First Name
Last Name
Contractor Phone
The phone number of the contractor you're working with.
Contractor Email
The email address of the contractor you're working with.
Description of Loss and Claim
Type of Damage (Hail/Wind/Fire/etc.)
*
Date of Loss/ Date of Damage
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address of Damaged Property
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like to be contacted this week regarding your property damage insurance claim?
*
Yes
No
Please Upload Insurance Policy
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Drag and drop files here
Choose a file
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Please Upload Damage Photos
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Choose a file
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Please Upload Other Relevant Docs
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Choose a file
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of
How did you hear about us?
*
Contractor / Roofing Company
Public Adjuster
Social Media (Facebook/Instagram/TikTok)
Google Search
Google Business Profile
Law Firm Referral
Friend / Family
Repeat Client
Other (please specify)
Description of Loss and Claim
*
Please give a brief summary of the loss and the progress of the claim as it stands today.
By checking the box above, you confirm that the information you provided is accurate and you consent to being contacted by Catastrophic Claims Legal Group (CCLG) PLLC and/or all associated law firms that work with CCLG. No attorney-client relationship or legal representation is formed unless and until a written representation agreement is fully executed.
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