Insurance Claims Assistance

Email *

Insured Name(s) (as on policy) *

Contact 1 Name *

Contact 2 Name

Address Line 1 *

City, State, Zip *

County *

Contact 1 Phone # *

Contact 2 Phone #

Contact 2 Email *

Are you the only owner(s)? *
YesNo

Occupied at time of loss? *
YesNo

Occupied by *
YourselfOthers

Primary residence? *
YesNoN/A

Alternate residence address (if needed)

Insurance Company *

Policy Number *

Effective Dates *

Mortgage? *
YesNo

Type of Loss *

Date of Loss *

Claim Filed? *
YesNo

Insurance Inspection Done? *
YesNo

Policy Declarations Page *

Relevant Claim Documents

Referred By
[text referred-by default:shortcode_attr "Matthew Dolloff" readonly class:form-control]

Contractor Name
[text contractor-name default:shortcode_attr "Maxx Roof Contractor" readonly class:form-control]

Contractor Contact
[email contractor-contact default:shortcode_attr "mattd@maxxroof.com" readonly class:form-control]