Customer Intake Form

1st Insured First Name *

1st Insured Last Name *

2nd Insured First Name

2nd Insured Last Name

Property Address *

City *

Postal code *

Customer Claim Contact Details (Phone & email) *

Insurance Carrier

Policy #: *

Claim #:

Claim Info

Client Fee

Public Adjuster *

Select

Gil Martin
Kevin Lugo
Marco Arcacha
Ryan Verdecia
Odlanier Morejon
Joe Test
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Claim Origin

Select

New Claim
Takeover
Reopen
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Details of Loss *

Cause of loss:

Date of loss:

Date of contract

Lead Source *

Where did the leads come from?

Lynk Pros
Public Adjuster
Third Party
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Services Requested

Mold Test

Bacteria Test

Roof Tarping

Water Mitigation

Dry-out

Mold Remediation

Leak Detection

Plumbing Repair

Sewer Camera

Structural Engineering

Moisture Mapping

Asbestos Test (pre-1979)

Lead Paint Testing (1979)

Soot/Smoke Test

Contents Inventory

Pack Out and Storage

Contents Cleaning

Contents Evaluation

Crime Scene Clean Up

Other

Contact Client To Inquire What Services Are Needed

Claim Notes

Remember to [Submit] then when you receive your receipt email, forward it with your claim documents to: assistants@alpha.claims