Fields with (*) are required.
Job Site Address
City*
First Name*
Last Name*
Mailing Address
City
ST
Zip
Phone Number*
Email Address*
Point of Contact for Emergency:
Job Type:*
Is this an emergency
Occupied?
Occupant Name:
Occupant Phone:
Office to Respond:*
Date of Loss:
Have you contacted your insurance?
How did you hear about us?
Insurance Claim?
Insurance Company:
Claim Number:
Deductible amount:
Insurance Phone Number:
Insurance Fax Number:
Mortgage Company:
Source of Damage:
Age of Structure
Standing Water?
Has the Water Stopped?
Is the Structure Occupied?
Have you contacted a Repair person?
Is there Electric Power Available?
Does the structure have heat?
Are there Special Concerns?
Is the Structure Secure?
Rooms Affected:
Flooring Type:
Furniture?
Property Management Company:
Property Management Phone:
Property Manager Name & Phone:
Recorded By:*
Lead Assigned To:*
Work Authorization Sent?