Claim Questionnaire - Gateway Public Adjusters LLC

Legal Name *

First

Last

Nickname

Are you the Named Insured? *

Yes
No

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

When did the loss occur? *

Date

Time

Where did the loss occur? *

Address Line 1

Address Line 2

City

State

Zip Code

Details of what happened:

Property Description *

Primary Home
Business/Commercial
Rental Home
Secondary Home

Business Name

Who are you insured through? (Insurance Company) *

Is there a mortgage company or loan?

Yes
No

Mortgage or Loan Company Name

Loan Number:

Do you have a forced placed policy by the mortgage company?

Have you filed a claim with your Insurance Company? *

Yes
No

Policy Number

Claim Number

Insurance Company Adjuster Name

Insurance Company Adjuster Phone Number

Insurance Company Adjuster Email

Has the Insurance Company made a payment

Yes
No
No - under my deductible

How many people reside at residence?

Approx SQFT of the Bldg:

Year Built

What is the Cause of the Loss?

Roof/Layers

When was the roof installed?

Any previous repairs on the roof?

Yes
No

Are there any Other Structures

Are the Other Structures attached to the home?

Yes
No
Some are
I don't know

Any remodels or additions on since purchase?

Yes
No

Was the carrier/agent notified of the remodel/addition?

Yes
No

Did you have to mitigate damage?

No
Yes - Tarp on roof
Yes- Board up
Yes - Muck out/Dryout

Personal Property/Contents Damage?

Yes
No

Business Property Damage?

Yes
No

Do you use a maintenance company?

Yes
No

Maintenance Company/Person

Any prior claims?

Yes
No

Did you hire a Public Insurance Adjuster?

Yes
No

Is the Prior Claim closed?

Yes
No

Was the work completed and depreciation released?

Yes
No
I don't know.

Cause of Loss

Any additional details:

Favorable Outcome with the prior claim?

Yes
No