Public Adjuster Agreement Form
Please enter as much of the following information as possible.
CONTRACTOR INFO
Contractor Company Name
*
ie. ABC Construction
Contractor Rep's Name
*
Your Name
Contractor Rep's Email*
*
HOMEOWNER INFO
Homeowner Name
*
First Name
Last Name
Homeowner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Homeowner's Email
*
example@example.com
Street Address
*
ie. 123 Apple St
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
CLAIM INFO
Insurance Company
*
StateFarm, Allstate, etc
Claim #
*
**** If claim is not filed yet, type "NEW CLAIM" ****
Date of Loss
*
Cause of Loss
*
ie. Hail, Wind, etc
Policy Number
Link to Photos
Company Cam / Acculynx URL Link
How many times has insurance been out for this claim?
*
Please Select
No adjuster appointment yet
Initial Adjuster came out
Reinspection has been done
Insurance sent an Engineer
Other (please explain below)
Please provide summary of the claim and any info we should know:
Any other info we should know? (Brief summary of what has happened thus far)
What are you hoping to get approved?
*
ie. Roof, Siding, Redeck, Interior Damaged, Matching, Pricing Increase, O+P, etc
PA Contract Info
Send PA Contract now? Or just looking for us to review?
*
Please Select
Yes, please send PA Contract to Homeowner
Not yet, just want Clarion to review.
Documents
Insurance Estimate / Denial Letter
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Contractor Estimate
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Measurements
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Eagleview, Hover, Roofr, etc
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ITEL/NTS Report (NEEDED FOR ANY MATCHING CLAIMS)
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Misc Doc 1
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Misc Doc 2
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Submit
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