INTRO FORM
Referral Company
*
Client 1 First Last
*
First Name
Last Name
Client 1 Phone Number
*
Format: (000) 000-0000.
Client 1 Email
*
example@example.com
Client 2 First Last (if applicable)
First Name
Last Name
Client 2 Phone Number (if applicable)
Format: (000) 000-0000.
Client 2 Email (if applicable)
example@example.com
Worksite Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this Project Insurance related, Out-of-Pocket, or not yet sure?
*
Insurance
Out-of-Pocket
Not Sure Yet
If Insurance, does Client already have a company doing mitigation work? Definition of Mitigation Work: in property claims/restoration it is the immediate, temporary actions taken right after a loss to stop or reduce further damage and make the site safe/stable—before permanent repairs. Typical tasks: water extraction and structural drying, board-up/tarping, temporary shoring, debris/water removal, isolating affected areas (smoke/soot/mold containment), and securing utilities—generally billed as necessary “emergency services” under the policyholder’s duty to mitigate clause
*
Yes
No
Not Relevant
If Insurance, Carrier?
If Insurance, Claim # if available
If Insurance, Adjuster Name if available
First Name
Last Name
If Insurance, Adjuster Phone Number if available
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Adjuster Phone Extension (if Generic phone number)
If Insurance, Adjuster Email if available
example@example.com
Brief Project Description
*
Are you the Referrer, Client, or In-House?
*
Referrer
Client
In-House
If you are the Referrer, is this an anonymous referral?
Yes
No
If you are the Referrer and an Adjuster, which Estimating software do you prefer?
Ie: Xactimate, Symbility, Other
If you are the Client, have you already communicated with us via Call, Text, and/or Email?
Yes
No
If you are In-House, was lead via Call, Text, or Email?
Call
Text
Email
TCN
If you are Referrer, please input any links pertaining to the Project
If you are Referrer, please input any links pertaining to the Project
If you are the Referrer, please upload any relevant attachments
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