Hurricane Claims Intake Form
 
 
Hurricane Claims Intake Form

Were you affected by Hurricane Katrina or Hurricane Rita?
If so, please call us at 1-866-242-0905 or continue on and fill out this form.
 
 
 
 

Hurricane Katrina Damage Claims must be filed by August 28, 2006.

Contact Information
Fill out the following form or call 1-866-242-0905 24 hours a day, 7 days a week for a Free Case Review.
* denotes a requied field
First Name*
Last Name
  only one phone number is required
Home Phone* - -
Work Phone* - -
Cell Phone* - -
Email Address*
Retype Email Address*
Street Address:
City
State/Zip  
 
Insurance Coverage Information
Who is your Homeowners insurance carrier?
How long have you been insured with this carrier?
Do you have a copy of your policy?
Yes
No
Do you have a copy of your application?
Yes
No
Do you have a copy of the "Dec Page" and Endorsements?
Yes
No
 
What are the stated limits in your policy for the following coverages:
Dwelling/Structure
Other structures
Contents/Personal property
Loss of use
Who was your previous insurance carrier? (if insured by present carrier less than 5 years)
 
What were the stated limits in your previous policy for the following coverages:
Dwelling/Structure
Other structures
Contents/Personal property
Loss of use
 
With respect to the Insured Dwelling/Structure:
What is the exact address of the insured property?
Please Describe your property?
(i.e. square footage, construction type, age, etc.)
How long have you owned the property?
What type of coverage do you have?
If "Extended", what amount?
Do you have "Code Upgrade Coverage"?
Yes
No
Do you have exclusion for "Mold"?
Yes
No
 
With respect to Loss of Use coverage, which does your policy provide:
Additional living expenses?
Yes
No
Fair rental value?
Yes
No
Do you have flood insurance?
Yes
No
If so, who is your flood insurance carrier?
What is your flood insurance policy limit?
 
Status of Claim
With your homeowner's insurance, please list all payments you have received from the insurance company under the following coverages:
Dwelling/Structure:
Other structures:
Personal property:
Loss of use:
Who is the adjuster(s) for the insurance company on your claim?
Was the adjuster(s) an employee for the insurance company or from an independent adjusting company?
(i.e. Wardlaw, Pilot, etc.)
Has a Scope of Loss been prepared?
Yes
No
If so, by whom?
Have you been asked for a personal inventory of items?
Yes
No
Were you given a form to fill out regarding these items?
Yes
No
Are you currently represented by a public adjuster?
Yes
No
If so, who is your public adjuster?
What is your public adjusters phone number?
Have you signed or been asked to sign a notice of "Intent to Rebuild"?
Yes
No
By whom?
Have you signed any documents?
(If so, please list)
With respect to your flood insurance, please list any payments you have received thus far:
Are you represented by a lawyer?
Yes
No
If so, who is your lawyer?
What is your lawyers phone number?
What is the current status of your claim?
What areas of dispute do you currently have with your insurance carrier?
Have you tried hired a contractor?
Yes
No
What is the name of the contractor?
What was the amount?
Have you received a bid and when was it provied?
Has your insurance company waived the 60 Day Proof of Loss Deadline?
Yes
No
If no, what is the date your sworn proof of loss is/was due?
Has your insurance company advised you or sent you notification regarding the 180 deadline?
Yes
No
 
Additional Comments
 
a. I agree that submitting this form and the information contained within does not establish an attorney client relationship.
b. I agree that my information will be reviewed by more than one attorney and/or law firm.
c. I agree that the information that I will receive in response to the above question is general information and I will not be charged for the response to this e-mail question. I further understand that the law for each state may vary, and therefore, I will not rely upon this information as legal advice. Since this matter may require advice regarding my home state, I agree that local counsel may be contacted for referral of this matter.

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