PCA Client Intake Form

Dear Policyholder(s):

Thank you for giving our firm the opportunity to represent your financial interest in your claim. In order to best represent you, we ask that you provide us with some basic information regarding your claim. You have likely already provided much of this information to your PCA Public Adjuster; We apologize for the redundancy.

Please provide us with the following information. Be as thorough as possible.

Name of your Property Claim Advocates Public Adjuster. (Not the name of the insurance company's adjuster)

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 currently living in the home that suffered damage? *

Yes
No
Yes but I need to move out

If someone referred our firm 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 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 that you would like to share with us or that you feel would help us better represent your financial interest in your claim. This may include good or bad things that the insurance company or their adjuster has done