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Date Of Loss

Type Of LossWaterFireVehicleWindOther

Customer's Name *(R)

Customer's E-mail *(R)

Customer's Phone # *(R)

Mailing Address

Tenant's Name

Tenant's Phone #Tenant's E-mail

Additional Phone # (1)Additional Phone # (2)

Loss Address

Rental PropertyYesNovacant

Insurance CoClaim #Deductible $

Adjuster's NameAdjuster's Phone #Adjuster's E-mail

Agent's NameAgent's Phone #Agent's E-mail

Type of DwellingHouse CondoApartmentCommercialSlabRaised Foundation

Number of StoryYear BuiltYear Remodeled Number Of Sq Ft

Type Of RoofTiteShingleRockSlateFlat

EMSMoisture Inspection OnlyLeak DetectionRepair EstimateComparison Estimate

Brief Description