Client Intake Form - Coppermark Public Adjusters Oklahoma

"*" indicates required fields

Client Information

What type of service are you needing?*

Property Type*

Policyholder Name*

First Last

Company Name

Loss Address*

Street Address City State ZIP Code

Is the mailing address different than the loss address?*

Mailing Address

Street Address City State ZIP Code

Policyholder Email*

Policyholder Phone Number*

Phone Type*

Text Permission*

Is Mortgage in good standing?*

Mortgage Company

Is the property for sale or will be listed soon?*

Who referred you to us?*

Referral Source Name*

Please describe what's going on with your claim

Additional Contact

Contact Name

First Last

Contact Phone

Contact Phone Type

Contact Text Permission

Contact Email

Is this person an Additional Insured?

Insurance Information

Insurance Company*

Policy Number

Claim Number*

Cause of Loss*

Date of Loss

When did you file your claim?

Insurance Adjuster, Supervisor, or Carrier's Appraiser Contact

Who have you talked to?

Rep Name

Rep Email

Rep Phone

Checklist of items needed for consideration of PA or Appraisal

Insurance carrier's most recent scope
Contractor's most recent scope
Insurance company correspondence (letters, emails, etc.)
Photos-Before, During, and/or After Build
Policy and Endorsements covering the date of loss

Please email these documents to claims@coppermark.claims. If you have photos, we will send you a link to upload them. If you have a photo link, please put it in the claim description box above.

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Name

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