Safeway Restoration

New Client Intake Form

Please Fill Out the Form Below

In order to best help you, we ask that you provide us with some basic information regarding your claim.

I am a named insured on the insurance policy and have a financial interest in the loss *

If you answered "yes" above you may skip this field. If you answered "no" above, provide your full name, phone number, and email address, state your relationship to the insured, and describe the role you will play in the insured's claim.

Your name, as shown on the insurance policy *

(please include all named insureds)

Your Phone Number *

Your Email *

If there are additional named insured's on the insurance policy (for example: a spouse), provide their name, phone number, and email here. If there are more that one additional insured's seperate their information using a comma. *Example: John Doe 206-555-4545 johnd@jmail.com, Tom Doe 509-555-8898 tom@hwoent.com

(please include all named insureds)

Location of Loss Address. (The address where the loss occurred) *

Mailing Address. (where you are receiving mail). If same as loss address enter the word "same" here

Date of Loss *

Cause of Loss *

Brief Description of Loss *

Are you currently living in the home that suffered damage? *

Yes
No
Yes but I need to move out

If someone referred our company to you, please tell us who it was.

Insurance Company Name *

Insurance Policy Number

Claim Number *

Insurance Company Adjuster's Name

Insurance Company Adjuster's Phone #

Insurance Company Adjuster's Email

Please describe the cause of the loss and briefly describe the extent of damage that it caused.

Please use this area to provide additional information you'd like to share with us.