Claim Intake

Company Name *

Email Address *

Requesting Service *

First Name

Last Name

Phone Number

Fax Number

Scope of work requested *

Scope of Work being Requested *

Cause & Origin/Structural Assessment Report (includes report, photo log, building diagram)Condition Assessment Field ReportEstimate for Repair PlansStructural repair plans for permit submittalInclude Permit Management Services

Billing Address Line 1 *

Billing Address Line 2 *

City *

State *

Zip Code *

Claim number

Date of claim

Insured's First Name *

Insured's Last Name *

Insured's Email Address

Loss Location Address Line 1 *

Loss Location Address Line 2 *

City *

State *

Zip Code *

Cell Phone Number

Work Phone Number

Other Phone Number

Home Phone Number