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Insured's Name

First Name

Last Name

Insured's Phone

(###)

###

####

Insured's Email

2nd Insured's Name

First Name

Last Name

2nd Insured's Phone

(###)

###

####

2nd Insured's Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance Company

Mortgage Company

If none, please put "N/A"

Cause of Loss

Date of Loss

If unsure, please give best educated guess.

YYYY

Claim Number

Please write N/A if not available.

Policy Number

Do you have exterior damage?

Yes

Unknown

If there is exterior damage, please provide brief description of damages.

If exterior damages are present, do you know how old your roof/siding is?

Do you have interior damage?

Yes

Unknown

If there is interior damage, please provide brief description of damages.

Do you have any prior claims related to this loss?

Yes

Do you have a local agent? If so, please let us know who it is.

If possible, please list their name, number, and email.

Did someone refer you?

Please list their full name here.

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