Insurance Claim Intake Form
Home Pro Contractor - Insurance Claim Intake Form (For Roofing Claims)
Full
Name
Email Address
Phone/Mobile
Preferred Contact Method
Phone
Email
Text
Property Address
Is this your primary residence?
Yes
No
Year Built
Roof Age
Previous Repairs/Claims
Yes
No
Description of Previous Repairs/Claims
Insurance Company
Policyholder Name
Policy Number
Insurance Policy Upload
Choose File
Claim Number
Date of Loss
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
Have you filed a claim?
Yes
No
Would you like assistance filing?
Yes
No
Preferred Date/Time for Inspection
How did you hear about us?
Signature
Sign Here
Date
Submit Form
No-Cost Roofing Estimate
First Name
Last Name
Email
Phone Number
Type of Inquiry
Type of Inquiry
Roof Repair
Roof Inspection
Roof Maintenance
Roof Replacement
Other
Message
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