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Adjuster Details
Company Name
Adjuster Name
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Fax Number
Cell Number
E-mail
Billing Address
City
State
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Zip
Are You the Assigned Adjuster?
- None -
Yes
No
Assigned Adjuster Name
Assigned Adjuster Phone Number
How Did You Hear About Us?
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Existing customer
Sales representative
Email or direct mail
Website
Advertisement
Trade show or event
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Other
Other
Who Should We Thank?
Claim details
Housing Requested
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Hotel Only
Long-Term Only
Hotel & Long-Term
Housing Fair Rental Value
Hotel Fair Rental Value
Claim #
Type of Loss
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CAT
Fire
Flood
Hail
Water Damage
Other
Lightning
Tree Damage
Vandalism
Car Through House
Adjuster Housing
Other Type of Loss
Date of Loss
Value of Property
ALE/Loss of Use Limit
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Dollar Amount
Time Period
ALE Dollar Amount
$
ALE Timeframe
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1 week
2 weeks
1 month
3 months
1 year
2 years
Unknown
Policy Type
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Homeowner
Condo
Renter
Other
Policyholder Details
Policyholder Name
Phone Number
Cell Number
E-mail
Permanent Address
City
State
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Connecticut
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District of Columbia
Florida
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Hawaii
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Illinois
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Kentucky
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Maryland
Massachusetts
Michigan
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Utah
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Washington
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Zip
Secondary Contact Name
Secondary Contact Number
Hotel Details
How Many Rooms are Approved?
Estimated Hotel Stay (Nights)
Max Approved Rate per Room
TA to Cover Pet Fee?
- None -
No
Yes
N/A
Current Living Details
Is Policyholder Currently in a Hotel?
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Yes
No
TA to Take Over Hotel Billing?
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Yes
No
Take Over Hotel Billing as of
Hotel Name
Hotel State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Hotel City
Hotel Phone Number
Occupant Details
Total Adult Occupants
Total Number of Children
Pets
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Yes
No
Pet Descriptions
On each new line, indicate the TYPE of pet (dog/cat); if the pet is a dog please indicate the BREED and WEIGHT.
Special Needs/Additional Information
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