Referral Type: Referral Type: Mitigation Restoration Appraisel

Insured / Resident Information

First Name:

Last Name:

Address:

Address 2:

City:

State/ Province:

Postal ZIP Code:

Assigned Franchise:

Telephone:

Evening Telephone:

Email Address:

Is the owner different? Is the owner different? Yes No

Policy Information

Policy Number:

Claim Reference #

Policy Limits:

Dwelling:

Contents:

Other:

Date of loss:

Type of loss:

Loss Information

Select a loss: Select a loss:MoldFireSmokeWater or SteamSewer Backup or Drain BackupFreezingFloodMechanical BreakdownSnow or Ice WeightNon emergency repairOther Casualties LossesHuuricaneTest ProjectBurglaryHailCollisionContamination or PollutionFalling ObjectEarthquakePower SurgePower InterruptionCollapseAnimal LiabilityAircraftGlassHeat Expansion or Cold ContractionLandslideMudslideLightningMoving and StorageRiotRobberySea WaterSinkhole or CollapseTheftTornadoTraumaVandalism or Malicious MischiefEnvironmental- Mold/AsbestosVehicleWind StormAll Water CausesSmoke/Fire DamageSumo Pump OverflowUndefine

Select Insurance Carrier: Select Insurance Carrier:American International Group Inc.Allstate Insurance GroupAmerica First InsuranceAmerican Capital AssuranceAmerican Strategic InsuranceAmeriprise Auto and HomeAmerican Family Insurance GroupAuto – Owners Insurance GroupCato CorporationCentury Fire ProtectionCentury 21 – Ron LaughlinChaga Mitigation AssignmentChubb Reconstruction AssignmentCitizen Property Insurance CPCode Blue TPAColorado Casualty InsuranceCalifornia State Auto GroupCypress InsuranceEncompass InsuranceErie InsuranceFarmers Insurance GroupFarmers Bureau in Terms of KentuckyFlorida Insurance Guaranty AssociationFireman’s FundForest Service BusinessGolden EagleHannahstown Mutual InsuranceHartford Insurance GroupHomeowners ChoiceHomesiteHomewise InsuranceIndiana InsuranceKettlerLiberty North WestMetLife Auto and Home GroupMontgomery Insurance CompanyMount Morris MutualNA Risk Insurance CompanyNarranganseth Bay Insurance CompanyNationwide Allied Insurance CompanyOhio Casualty GroupOlympus Insurance CompanyPDN Select Commercial AccountsPeerless InsuranceSafeco Insurance CompanyService AmericaStar and ShieldState AutoState Farm RouteUniversal North AmericaUSAA GroupWest Bend Mutual InsuranceYellow-RoadwayOther