First Name
Last Name
Address
City
State
Postal code
Email
Phone
Are They the Property Owner?
Yes
No
Property Owner Full Name
Property Owner Phone
Residential or Commercial?
Residential
Commercial
Age of Roof
Is This a Rental Property?
Yes
No
Is The Property Vacant?
Yes
No
How Many Stories is the Property?
1 Story
2 Story
3 Story
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Are There any Current Leaks or Missing Shingles?
Yes
No
Where Are the Current Leaks, or Missing Shingles?
How Long Have You Noticed the Leak For?
Has There Been any Previous Repairs Made in the Past?
Yes
No
Where Was the Previous Repair Made?
Are There any Dormers or Skylights?
Yes
No
Add How Many Dormers or Skylights
Has an Insurance Claim Been Started Yet?
Yes
No
Insurance Company
AAA
Aegis
AIG
Alfa
Allstate
American Family
American Reliable
Amica
Assured Partners
Cabrillo Coastal
Centauri/AUW
Chubb
Coastal American
Farm Bureau
Geico
Great American Insurance Group
Harbor Claims
Hippo
HUB
Liberty Mutual/Safeco
MetLife/Farmers
Nationwide
Progressive/ASI
Pure
QBE
Shelter
State Auto
State Farm
Travelers
USAA
Other
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List is empty.
Enter Other Insurance Not Listed
Have You Met With Your Adjuster Yet?
Yes
No
Adjuster First Name
Adjuster Last Name
Adjuster Phone
Adjuster Email
Is This a Gated Community?
Yes
No
Gate Code
Add any additonal notes here
Which Location is The Customer Closest To?
Madison
Madison
Hattiesburg
Brookhaven
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