intake-form | Floor Claim Assist L

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Floor Claim Intake Form

This is the first step to create a clear, claim-ready flooring documentation package for contractor, supplier, insurance and dispute resolution.

Full Name of Property Owner*

Property Address*

Mailing Address (if different)

Email Address*

Phone Number

Are you the ...*

Date you first noticed problem*

Date of Loss, If known

Has the issue been reported to insurance?*

Yes

No

Insurance Carrier Name

Insurance Claim Number

Insurance Policy Number

Claims Adjuster Name (if known)

Claims Adjuster Phone Number

Claims Adjuster Email Address

Is a Public Adjuster involved?

Yes

No

Public Adjuster Name (if known)

Public Adjuster Phone Number

Public Adjuster Email Address

Is an Attorney involved?

Yes

No

Attorney Name / Firm Name

Attorney Phone Number

Attorney Email Address

Is a Contractor or Restoration company involved?

Yes

No

Contractor / Restoration Company Name

Contractor / Restoration Company Phone Number

Contractor / Restoration Company Email Address

What type of flooring issue are you dealing with?

Briefly describe the issue*

Do you already have photos, invoices, product names, or inspection reports? *

Yes

No

Not Sure

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Documentation Support & Report info@floorclaimassist.com

656-225-3330

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