Step 1 of 2 50% Name* First Last Phone*Email* Date of Loss* MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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?* Yes No Squares at Roof Pitch (Slope) 7/12-9/12*Please enter a number from 0 to 100.Squares at Roof Pitch (Slope) 10/12-12/12Please enter a number from 0 to 100.Squares at Roof Pitch (Slope) 13/12 - 15/12*Please enter a number from 0 to 100.Squares 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?* Yes No Number 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.Max. file size: 98 MB.