Intake Form - Contractor Completed

General

Please fill out the following information.

First Name

Last Name

Phone

Opportunity Overview Enter a summary of the opportunity, including relevant details about the loss, and identify the source of the opportunity (roofer, contractor, referral, agent, marketing, direct call, etc.)

Loss Address

Enter the location of the property where the loss occurred.

Street Address

City

State

Zip Code

Insurance Information

Enter available insurance data

Claim Type / Status

Insurance Provider Name

Insurance Contact First Name

Insurance Contact Last Name

Insurance Contact Email

Insurance Contact Phone

Claim Number

Policy Number

Loss Type

Policy Deductible

Loss Date

Contractor Information

Contractor Contact First Name

Contractor Contact Last Name

Contractor Contact Phone

Contractor Contact Email

Add Files

Upload any documents that are relevant to this claim. Files like a copy of the insurance policy help us expedite the process.

Click to Upload File Here Max file size 50MB. (For all files total) Please be patient with uploads.

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