Insurance/Relocation Housing Request

Insurance/Relocation Housing Request

Please fill out the form below.
Emergency (within 24 hours)Within 3 daysWithin 1 weekFlexible
Adjuster/Coordinator Information
Full Name

First NameLast Name
Company Name
Email Address
example@email.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Best Way To Communicate
Phone/Email/Text
Preferred Contact Hours
Claim Information
Name

First NameLast Name
Insurance Company
Claim Number
Type of Claim
Is the Claim Approved For Temporary Housing?
Expected Claim Duration?
(if known)
Displaced Resident Information
Name

First NameLast Name
Property Address of Loss

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Number of Adults
Number of Children
Ages, if possible
Pets?
Type of Pet
e.g., Dog, Cat
Breed & Weight
Housing Requirements
Desired Move-In Date

MonthDayYear
Date
Estimated Length of Stay
Minimum 30 Days
Preferred Area/Neighbourhood
Minimum Bedrooms Required
Minimum Bathrooms Required
Minimum Bathrooms Required
Parking Required?
Ground Floor / Accessibility Required?
Elevator Required?
Fully Furnished Required?
Laundry Required?
Work-From-Home Space Required?
Quiet Environment Needed?
Pool Required?
Budget / Insurance Coverage
YesNo
Maximum Monthly Housing Allowance
YesNo
YesNo
Billing Information
Insurance CompanyThird-Party Housing ProviderGuest Reimbursement
Billing Contact Name

First NameLast Name
Billing Email
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lease & Documentation
YesNo
AdjusterInsurance CompanyGuestOther
Additional Notes
Please Include Any Special Circumstances or Housing Considerations
Ex. mobility issues, emotional support animals, storage needs, school proximity
Should be Empty:

Insurance/Relocation Housing Request

Adjuster/Coordinator Information

Claim Information

Displaced Resident Information

Housing Requirements

Budget / Insurance Coverage

Billing Information

Lease & Documentation

Additional Notes