For Internal Use Only

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

: HH

MM

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