Please enable JavaScript in your browser to complete this form.Customer Intake FormSo that we can better serve you, please provide us with as much detail as possible about your current insurance claim situation.Address of Loss *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeInsured's Name *FirstLastInsured's EmailInsured's Phone *Additional Insured's NameFirstLastAdditional Insured's EmailAdditional Insured's PhoneInsurance CompanyInsurance Company Name *Policy NumberClaim NumberClaim Status *NewDeniedLoss below deductibleSupplement/Re-openedOtherDate of LossType of Loss *Water damageWindHailWind/HailFireHurricaneFloodPipe breakVandalismOtherMultipleSpecify Type of Loss *Losses Sustained *Insurance AdjusterInsurance Adjuster's PhoneWas an insurance estimate provided? *YesNoNot ApplicableHave there been any payments issued? *YesNoContractor Information*If applicable*Company NameCompany ContactFirstLastContractor EmailContractor PhoneAny Additional Relevant Information Regarding the ClaimThis may include claim history, how the damage was found, etc.MortgageIs there a mortgage on this property? *YesNoUnsureName of the mortgage company:Claim DocumentsDocument Upload Click or drag a file to this area to upload. Policy, estimates, and any written correspondence from the insurance company.Prior Claim HistoryHas there been any prior claims for this property? *YesNoWhat was the prior claim for? *Date of Prior Claim?How did you hear about us? *Referred by a friendReferred by a contractorGoogle SearchFacebookAdvertisementOtherSubmit