We are ready to help you with your claim.

The following information is needed so we may begin assisting you.

How Did You Hear About Us?

Your First and Last Name Or Name of Business

Exactly As Policy States

Date of Loss

"If Unknown Input Today's Date"

YYYY

Email Address to Contact

Contract Will Be Sent To This Address For Signature

Any Other Name Listed On Policy?

If Yes, Please Provide Other Name On Policy

Per TDI Guidelines Our Contract Requires All Names Listed On Policy

If Yes, Please Provide Email Address For Other Named

Contract Will Be Sent To This Address For Signature

Year Property Purchased (Deed Date)

Street Address of Property

City

State

Zip / Postal Code

Phone

(###)

###

####

Preferred Method Of Contact

Type of Property

Type of Loss

Hail Damage

Wind / Hurricane / Tornado

Flood

Water Loss - Pipe Break

Lightning Damage

Fire Damage

Other

Cause Of Loss

If Other, Please Explain

Are You Experiencing Interior Leaks at This Time?

Yes

If Yes, Please Provide Details Below

Damage Severity

Insurance Carrier

Claim Number (If You Have Not Filed Enter NEW)

Policy Number

What Type of Policy Do You Have?

Mortgage Company

Both you and the Mortgage company may be listed as having an interest in the property on the policy. Any claim payment checks will be written to both of you. If you do not have a Mortgage enter "None".

Mortgage Loan Number

If you do not have a Mortgage enter "None".

Are You Current On Mortgage Payments?

Insurance Claim Status

Date Claim Filed

If You Filed a Claim, What Was The Date You Notified Insurance

YYYY

Enter Email Address of Adjuster Who Has Contacted You

If Claim Has Not Been Filed Or You Have Not Been Contacted Enter N/A

Amount (If Any) You Have Been Paid By Insurance Carrier

Verified Amount Will Not Be Included In APIA Source Adjustment Of Supplement

Your Deductible Amount

You Can Find This On Your Declarations Page Of Policy

Any Other Helpful Information We Should Know?

List All Claims Filed For This Property In The Last Five Years

Please Include Date and Amount Of Settlement(s)

We are ready to help you with your claim.

The following information is needed so we may begin assisting you.

TERMS AND CONDITIONS PRIVACY POLICY