Home Pro Contractor - Insurance Claim Intake Form (For Roofing Claims) (#5)
Full Name
Email Address
Phone/Mobile
Preferred Contact Method
Phone
Email
Text
What type of service are you looking for?
New Roof Installation
Roof Repair
Emergency Tarping/Service
Roof Inspection
Other (Please Specify Below)
If you chose 'Other', please describe your roofing problem in the space below.
Property Address
Roof Age
Do you have a Insurance Claim in progress or Looking to FIle a Claim ?
Yes
No
Would you like to share Insurance Information (Optional)
Yes
No
Insurance Company
Policyholder Name
Policy Number
Insurance Policy Upload
Choose File
Claim Number
Date of Incident
Type of Damage
Hail
Wind
Water
Other
Adjuster Assigned?
Yes
No
Adjuster Name
Adjuster Contact
Areas Affected
Roof
Siding
Gutters
Windows
Other
Visible Damage
Missing Shingles
Dents
Leaks
Granule Loss
Structural Issues
Additional Notes
Would you like assistance filing?
Yes
No
Signature
Sign Here
Date
Submit Form
