Sales Rep Claim Form

Sales Representative Claim Submission Form

Please fill out the form below with all needed and available information to create a job in Restornet.

Sales Representative Claim Form

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GENERAL CLAIM INFORMATION

Loss Reported:

Referral Source:

Date of Loss:

Call-In Contact Name:

Payer:

Contaminant:

Job Description:

Job Type:

Coverage Concerns:

Emergency Response Required:

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__________________________________

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INSURANCE INFORMATION

Insurance Company Name:

Adjuster Name:

Claim Number:

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ADD/UPDATE ADJUSTER INFORMATION

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CONTRACTOR INFORMATION

Contractor Company Name:

Contractor Contact Name:

Referral Fee:

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ADD/UPDATE CONTRACTOR INFORMATION

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HOMEOWNER INFORMATION

Insured Name:

Insured Address:

Insured City:

Insured State:

Insured Zip Code:

Insured Contact Number:

Insured Contact Number Note:

Insured Contact Number (Alt)

Insured Contact Number (Alt) Note:

Insured Email Address:

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