For Internal Use Only

Manual Deal Creation

This form is for adding leads to Pipedrive.

Contact Info
Main Contact
First Last
Main Contact Phone
Main Contact Email
Claim Details (Optional)
Insurance Company
Cause of Loss
Policy Number
Policyholder
Policy Type
Claim Number
Loss Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Comments

Mutual Referral Partner Follow-Up

This form is for referral sharing.

The email does not reference the referral program.

Stakeholder Referral Partner Follow-Up

This form is for insurance brokers and real estate brokers.

This email does reference the referral program.

Create a New Deal

Type
Entry Type*
Has The Claim Been Submitted?*
Do You Have A Claim Number?*
Contact Info
Main Contact
First Last
Main Contact Phone
Main Contact Email

Date of Initial Contact
Time of Initial Contact

: Hours

Minutes

Contract Details
Contract Reviewer Email

Public Adjuster Email

Retainer Rate

Our Claim No.
Date Signed
Loss Details
Date Of Loss

Type Of Loss

Loss Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Claim Details
Insurance Company

Policy Number

Policyholder

Policy Type

Claim Number

Coverages Involved

Main Contact Address
Street Address Address Line 2 City State ZIP Code

Our Assessment (Optional)
Cause of Loss

Estimated Loss Size

Mitigation Company

Scope of Damage
Comments

Letter of Representation

Contact Name*
First Last
Contact Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policyholder Name*

Policy Number*

Claim Number

Type Of Loss

Date Of Loss

Date Of Initial Contact*

Time Of Initial Contact*

Loss Location
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policyholder Email

Reviewer Email

Public Adjuster Email

Phone
Rate*

Regulation 10

Name of Insured

Contact Name

Policy Number

Claim Number

Email

Inventory Form

Name of Insured

Policy Number

Claim Number

Email

Proof of Loss - Building

Contact Name

Contact Email

Policy Number

Claim Number

Policy Amount

Policy Dates

Insurer

Insurer Address

Insured Name

Loss Location

Type of Loss

Date of Loss

Occupancy Type

Interest Percentage

Others

Changes

Property Value

Agreed Loss Amount

Deductible Amount

Depreciation Amount

Claimed Amount

Proof of Loss - Other Structures

Proof of Loss - Contents/BPP

Employment Contract - 1099

Candidate Information
Candidate Name
First Last
Candidate Email

Reviewer Information
Reviewer Name
First Last
Reviewer Email

Manager Information
Manager Name
First Last
Manager Email

For Internal Use Only

Manual Deal Creation

Contact Info

Claim Details (Optional)

Mutual Referral Partner Follow-Up

Stakeholder Referral Partner Follow-Up

Create a New Deal

Type

Contact Info

Contract Details

Loss Details

Claim Details

Our Assessment (Optional)