Insured Contact Name *

First Name

Last Name

Customer Phone *

(###)

###

####

Type of Loss *

Hail Damage

Wind / Hurricane / Tornado

Flood

Water Loss - Pipe Break

Lightning Damage

Fire Damage

Other

Date of Loss

"If Known, Enter Today's Date if Unknown".

MM

DD

YYYY

Are They Experiencing Interior Leaks at This Time?

Yes

No