Policy Holder's First and Last Name*
Property Address, City, State and Zip Code*
Policy Holder's Phone Number*
Policy Holder's Email Address*
Name of Property or Business*
Did you file a claim? If so, when?*
Name of Insurance Company*
Insurance Company's Phone Number?*
Adjuster's Name, Phone Number and Email Address*
Was a field adjuster sent out by your insurer? If so, when?*
Have you received an estimated cost(s) of damage(s) from your insurer?**
Has payment been made on any part of the claim?*
Was damage that caused loss repaired/mitigated?*
Name, address and phone number of repair/mitigation company?*
Has contractor estimates been provided? List contractor information*
