WinGate Claim Valuation Form

1
Please Tell Us Your Name* This field is required.
First Name
Last Name
2
What is the Name of Your Business?
3
What is the work completion date?* This field is required.
4
What is the approximate balance remaining on the receivable? * This field is required.For example, If you have received a payment from your customer as a down payment be sure to subtract that amount.
Override placeholder value with the correct balance of your claim.
5
Was all of the contracted work satisfactorily completed?* This field is required.
YESNO
6
Insurance Carrier* This field is required.What is the insurance company of the policy holder?
Please Select
Please Select
All-State
American Family
Amica
Badger Mutual
Chubb
Colorado Farm Bureau
Country Financial
Farm Bureau
Farmer's
Hartford
Liberty Mutual
Mountain West Farm Bureau
Nationwide
Praetorian
Progressive
QBE
Safeco
State Farm
Traveler's
USAA
Other
7
What is the best number to reach you?* This field is required.Cell phone or direct line please.
8
Do you have a signed authorization stating that all work will be completed per approved insurance scope?* This field is required.
YESNO
9
Any other details to assist us in the valuation of your claim?
10
What is a direct e-mail for you?* This field is required.
example@example.com
11
WinGate Financial Partners, LLC is an independent investor that specializes in insurance claim receivables. By submitting your information along with the claim to be considered you are authorizing Wingate Financial to review the claim, estimate, policy holder and scope of work in order to determine the appropriate amount to be offered. No offer has been made at this stage and WinGate Financial Partners, LLC has no obligation to make any offer if it at it’s sole discretion finds the receivable to be outside of WinGate Financial Partners, LLC parameters for doing so.* This field is required.
Should be Empty: