561-268-8988 | claims@completeconstructionfl.com | Mon – Fri: 9:00 – 4:30 | CGC1514380 | CCC1328852

File Intake Form

Please take a moment to fill out the following form. This form allows our office to run an accurate conflict check and helps verify all information for the matter at hand.

Please provide as much information as possible.

Thank you!

Insured Full Name:

Insured Full Name:

Property Address:

Property Address:

Claim Number(s):

Claim Number(s):

Carrier:

Carrier:

Cause of loss claimed:

Cause of loss claimed:

Name of the Handling Attorney and Firm:

Name of the Handling Attorney and Firm:

Handling Attorney’s phone number:

Handling Attorney’s phone number:

Please provide the name & email of the person who we should contact for billing purposes:

Please provide the name & email of the person who we should contact for billing purposes:

Please provide any other information you think is necessary for our file in this section:

Please provide any other information you think is necessary for our file in this section: