Insurance Housing Request Form, Temporary and Emergency Housing Services

*All rental applications are subject to credit check

Request for Information

*Adjuster’s Full Name:
*Insurance Company:
Billing Address Line #1:
Billing Address Line #2:
City: , State: , Zip
*Adjuster’s Office Phone Number:
Adjuster’s Cell Number:
Adjuster’s Fax:
Adjuster’s E-Mail:
Claim Number:
*Policy Holder’s Full Name:
*Date of Loss:
*Type of Loss: (Fire/Wind/Water/Other)
ALE Limits:
*Damaged Property Address:
*City , *State , *Zip
*Estimated Sq.Ft. of damaged home:
Number of Acres of home lot:
Year Home was built:
How many levels of home:
Type of garage: car
*# of BDRM:
*# of BATHRM:
Pool? , Spa?
*# Adults: , *# Children:
*Pets: How many , Breed , Weight ; 2nd Pet: Breed / Wt.
*Type of Housing needed:
*Size desired: BDRMS: ; BTHRM:
*Location desired: ; Boundaries:
Close to this specific address w/ zip:
Do you need a Fair Rental Value (FRV) Analysis Performed?
(note - If yes, complete our FRV form upon submission of this application)

Hotel:
*Do you need a hotel?
(note - If yes, complete our Hotel form upon submission of this application)

Currently staying in Hotel? ; Hotel Name: ; Hotel Phone # Rm.#:

Additional Info / Comments:

Type the code shown on the image at the above: