Client Information Named Insured Email Address Phone No. (main) Phone No. (other) Property Details Address City State ALCAFLGATX Zip Claim Details Insurance Company Insurance Company Policy Number Claim Type Non-EmergencyEmergencyRe-OpenTake Over Original Claim No. Claim Denied? NoYes Payment Received? NoYes Type of Loss Date of Loss Policy Has 10K Limit? NoYes Damaged Areas -- Select a Template -- Kitchen - Source Unknown Kitchen - Source Known Bathroom - Source Unknown Bathroom - Under Sink Bathroom - Shower Pan A/C Leak Water Heater From Above or Below (Apartments) Through Window Underground Pipe Damage Storm, Wind, or Hail Damage Fire Damage Public Adjuster -- Select One --Jose Linan Claims Adjuster -- Select One --Jose Linan Fee Signatures Enter Named Insured Enter Additional Insured Today's Date Services Please indicate if the following services are needed: Water Mitigation NoYes Plumber NoYes Tarp NoYes Checklist: Please indicate whether the following documents have been attached: Insurance Policy NoYes Picture of Client Ids NoYes Mortgage Statment NoYesNot Applicable Repair Invoices NoYesNot Applicable Photos NoYes Δ
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