Step 1 of 2 50% Name* First Last Phone*Email* Date of Loss* Date Format: MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company*First ChoiceSecond ChoiceThird ChoiceClaim Number*Claim Adjuster Name First Last Adjuster Phone*Adjuster Email* Shingle Type*3-TabLaminated ArchitecturalLaminated Class IV - Impact ResistantTotal Squares*Please enter a number from 1 to 100.Is the slope or pitch of your roof listed on your claim document?*YesNoSquares at Roof Pitch (Slope) 7/12-9/12*Please enter a number from 0 to 100.If this information is not listed on your claim document please enter 0Squares at Roof Pitch (Slope) 10/12-12/12*Please enter a number from 0 to 100.If this information is not listed on your claim document please enter 0Squares at Roof Pitch (Slope) 13/12 - 15/12*Please enter a number from 0 to 100.If this information is not listed on your claim document please enter 0Squares RemainingThis value is calculated automatically based on the squares values you entered in the previous questions. The value will be 0 if you entered the squares information correctly.Does your home have more than 1 story?*YesNoNumber of Squares on 2nd Story*Please enter 0 if your home doesn't have a 2nd story.Continuous Ridge Vents (LF)*Please enter a number from 1 to 500. Replacement Cost Value (RCV) of Roof ONLY*Total Replacement Cost Value (RCV) of ALL Items*Deductible*Total NET CLAIM*Please upload your claim documents if possible. You can also email them after you submit this form.
