Intake Sheet

A. Client Information

Name Of Insured: Phone:
Name Of Insured: Phone:
Email Address Preffered Language:
Property Address:

B. Insurance Policy Details

Insurance Company:

Policy No:

Claim No:

C.Loss Details

Type Of Loss:

  • A/C LEAK
  • ROOF LEAK
  • HURRICANE/WIND
  • FLOOD
  • WATER DAMAGE
  • KITCHEN
  • BATHROOM
  • LAUNDRY
  • BROKEN PIPE
  • KITCHEN
  • BATHROOM
  • LAUNDRY

Date Of Loss:

  • MOLD
  • FIRE
  • OTHER

Description Of Loss:

Preferred DAY / TIME for inspection:

Add Your HeadiAppraiser or Public Adjuster:

Representative:

Mortgage Company:

ATTORNEY / LAW FIRM:

Water damage RESTORATION Co.:

Have you received payment for your claim?       Yes   No                Has your claim been denied?         Yes       No

NOTES:

  • ESTIMATE(S)
  • EMS INVOICE
  • PLUMBING INVOICE
  • TARP INVOICE
  • SPOL
  • RECORDED STATEMENT
  • WATER DAMAGED
  • OTHERS:-------------------------------------------