Adjuster Information
Adjuster's Name:
(Required)
Insurance Company
Name: (Required)
Billing Address:
City:
State:
Zip:
Adjuster's Phone Number:
(Required)
Adjuster's Fax:
Adjuster's Email Address:
Policyholder Information
Policyholder Full
Name:
Spouse Full Name:
Street Address of
Damaged Property:
City:
State:
Zip:
Policyholder Contact
Phone:
Policyholder Alternate
Phone:
Is Policyholder in
a Hotel?
yes
no
If yes, hotel name:
Hotel phone:
Hotel Fax:
Claim Information
Claim number:
Date of Loss:
Estimated Length of
Repairs:
Type of home
Single Family
Duplex
Row
Condo
How many bedrooms:
Total Number of People
in Family:
Pets:
Desired Relocation
Areas:
A.L.E. Guidelines
/ Limits / Budget?