The Justice Coalition

Full Name *

Date of birth

Phone *

Email *

Address

State *

Postal code *

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Names and ages of everyone who lived in your home with you *

Affected Property Address *

How much did you purchase your home or other property for? *

If anyone owns a portion of the property damaged beyond yourself, who are the owners of the home/business?

What is your estimate of the value of your damaged home or other property?

How much is owed on the mortgage?

Did you have any type of fire insurance? *

Yes

Insurance Provider (If applicable)

Please send us a copy of your policy and declaration page.

what are the policy limits on your homeowners and other policies?

Have you had any communication with your insurance company? *

Yes

If yes, please send us copies of all communications.

Are there any exclusions for wind, fire or water in the policy that you are aware of? *

Yes

If so, please state:

Is your home or business a total loss or partial? *

Total Loss

Partial Loss

If you have photos of the damage please provide them.

Was your car damaged or destroyed?

Damaged

Destroyed

Neither

If so, please send us a copy of your automobile insurance policy.

What kind of car did you have?

Year?

Was it owned or leased?

Owned

Leased

How much, if anything, do you owe on the vehicle?

How much did you pay for your car?