CUSTOMER DETAILS
Customer Name
*
Customer Phone Number
*
Can we text you at this number?
Yes
No
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Customer Email Address
*
JOB DETAILS
Loss Details
*
Where are you seeing the issue?
*
Is There Standing Water
*
Yes
No
Is Water Still Leaking?
*
Yes
No
Have you called a plumber or any other professionals? If so who?
*
What type of home or building is it?
*
Single Family Home (Multi Story)
Single Family Home (1 Story)
Apartment
Condo
Town House
Duplex
Commercial Building/Business
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Is this a 2 hour Emergency Response Job?
*
Yes
No
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Who is the owner of the property?
*
Age of Property
*
Do you have power?(Electricity)
*
Yes
No
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ADDRESS
Street Address
*
City
*
State
*
Zip code
*
INSURANCE INFO
Have You Contacted Your Insurance?
*
Yes
No
Insurance Company
*
Who is your Agent?
*
Agent Phone Number
Agent Email
CLAIM INFO
Have you filed a claim?(If Applicable)
Yes
No
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Claim Number
Adjuster Name
Adjuster Phone Number
Adjuster Email Address
SECONDARY CONTACT
Tenant, spouse, property manager, etc.
Secondary Contact Name
Secondary Contact Phone
LEAD SOURCE INFO
How did you hear about us? Did someone refer us to you?
*
Google
Yelp
Insurance Agent/Company
Referred by a Friend
Referred by a Business
Repeat Customer
Anji Leads
Other
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Lead Source Notes(Name Agent/Person/Company who referred or "Other" notes of Lead Source)
Additional Notes
Yes, Opt-In For Text Reminders & Information, and I agree to
privacy policy
provided by the company.
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