INTAKE
FORM

Initial Contact

Referral / New Assignment From:*

Project Manager:

Type of Loss:

Controller:

Name:

Email

Address:

Phone

Policy Number:

Claim Number

DOL

Loss Description:

Special Instructions:

Coverage Information:

Name:

Email

Phone

Initial Assessment Questions

How and where did the loss originate?

Are you currently residing at the property?

Which areas of the property have been directly affected?

Have you been contacted by your adjuster and/or mitigation company?

Do you currently have a contractor assigned for the reconstruction?

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