First Name: Last Name: Your email: Phone: Type of Damage Blasting DamageBroken PipesCast Iron Pipe DamageCollapseEnvironmentalFireFloodHailHurricaneLightningMold & MildewPersonal PropertyRoof LeakSettling or CrackingSewerSinkholeSmokeStormStructural ImpairmentTheft or VandalismTornadoWaterWindOther Date of Loss Who is your Insurance Provider: Estimated Damage Amount:$ Did you sustain any damage to your personal property (e.g., motor vehicle, boat, furniture, clothing, jewelry, art, writings, or household goods)?: YesNo Estimated Personal Property Damage Amount?: $ Has your insurance company refused to honor or pay your claim?: YesNo Have you been asked to provide a "prove of loss" by your insurance company?: YesNo If yes, how soon after the request did you provide "proof of loss" to your insurance Company?:> 30 days or less60 days or lessMore than 60 days Have you previously retained a Public Adjuster?: YesNo Have you previously retained a lawyer?: YesNo Brief Description Please do not include any confidential or sensitive information in this form. This form sends information by non-encrypted e-mail which is not secure. Submitting this form does not create an attorney-client relationship.
