* First Name

* Last Name

* Primary Phone Number

Alternate Phone Number

Are You the Property Owner? Are You the Property Owner? Yes No

* Is This An Emergency? * Is This An Emergency? Yes No

Company

* Email Address

Are You An Insurance Professional? Are You An Insurance Professional? Yes No

Approximate Square Feet of Structural Damage

Rooms Affected

Please Describe Contents Damaged in Loss

Insurance Claim Number

Insurance Adjuster Phone

Insurance Agent / Broker Phone

Description of Loss

Materials Affected

Has Insurance Company Been Notified? Has Insurance Company Been Notified?YesNo

Name of Insurance Adjuster

Name of Insurance Agent / Broker

Special Instructions

Property Owner Name

* Damaged Property #1 - Address, City, State and Zip Code

Damaged Property #2 - Address, City, State and Zip Code

Name of Insurance Carrier

* Loss Location Type * Loss Location TypeResidentialCommercialIndustrialOther

Loss Type Loss TypeWaterFloodMoldHailTornadoHurricane

Details of Loss

* Date of Loss

Check All That Apply Check All That Apply Structure Has No Power Water is Inside or Coming Into the Structure Structure Cannot Be Occupied Building Envelope is Damaged (Roof, Walls, Etc.) Some Contents Are Damaged

How Did You Hear About the Kings Mitigator? How Did You Hear About the Kings Mitigator?Insurance CompanyRealtorPrevious ClientFriendAdvertisementInternet SearchOther

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