Forms - Guardian Public Adjusters

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Customer Intake Form

So 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 1

Address Line 2

City

State

Zip Code

Insured's Name *

First

Last

Insured's Email

Insured's Phone *

Additional Insured's Name

First

Last

Additional Insured's Email

Additional Insured's Phone

Insurance Company

Insurance Company Name *

Policy Number

Claim Number

Claim Status *

Date of Loss

Type of Loss *

Specify Type of Loss *

Losses Sustained *

Insurance Adjuster

Insurance Adjuster's Phone

Was an insurance estimate provided? *

Yes
No
Not Applicable

Have there been any payments issued? *

Yes
No

Contractor Information

*If applicable*

Company Name

Company Contact

First

Last

Contractor Email

Contractor Phone

Any Additional Relevant Information Regarding the Claim

This may include claim history, how the damage was found, etc.

Mortgage

Is there a mortgage on this property? *

Yes
No
Unsure

Name of the mortgage company:

Claim Documents

Document Upload

Click or drag a file to this area to upload.

Policy, estimates, and any written correspondence from the insurance company.

Prior Claim History

Has there been any prior claims for this property? *

Yes
No

What was the prior claim for? *

Date of Prior Claim?

How did you hear about us? *

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