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Date Of Loss

Type Of Loss Water Fire Vehicle Wind Other

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 Property Yes No vacant

Insurance CoClaim #Deductible $

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

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

Type of Dwelling House  Condo Apartment Commercial Slab Raised Foundation

Number of StoryYear BuiltYear Remodeled Number Of Sq Ft

Type Of Roof Tite Shingle Rock Slate Flat

 EMS Moisture Inspection Only Leak Detection Repair Estimate Comparison Estimate

Brief Description