1.1. OS INTRO FORM

Referral Company

Client 1 First Last

First NameLast Name

Client 1 Phone Number

Format: (000) 000-0000.

Client 1 Email

example@example.com

Client 2 First Last (if applicable)

First NameLast 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

CityState / Province

Postal / Zip Code

Is this Project Insurance related, Out-of-Pocket, or not yet sure?

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

If Insurance, Carrier?

If Insurance, Claim # if available

If Insurance, Adjuster Name if available

First NameLast 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?

If you are the Referrer, is this an anonymous referral?

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?

Is Client able to fill things electronically? (HIGHLY PREFERRED)

If you are In-House, was lead via Call, Text, or Email?

If you are Referrer, please input any links pertaining to the Project

If you are the Referrer, please upload any relevant attachments