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HOME
ABOUT
SERVICES
CLAIMS
Storm Damage
Earthquake Damage
Large Loss Claims
Tile Roof Damage
Wood Shake Roof Damage
BLOG
CONTACT
NEW CLIENTS
CLIENT PORTAL
Client Intake Form
Fraziercreative
2021-09-21T09:53:59-05:00
Client Information
What type of service are you needing?
*
Public Adjusting
Appraisal
Not Sure
Property Type
*
Residential
Multifamily
Commercial
Unknown
Policyholder Name
*
First
Last
Company Name
Loss Address
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the mailing address different than the loss address?
*
No
Yes
Mailing Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
*
Phone
*
Phone Type
*
Mobile
Office
Home
Fax
Text Permission
*
Yes
No
Is Mortgage in good standing?
*
Yes
No
I don't have a mortgage
Mortgage Company
Is the property for sale or will be listed soon?
*
No
Yes
Who referred you to us?
*
Contractor
Facebook
Existing/Previous Client
Friend/Family
Public Adjuster
Google
Website
Public Relations/Event
Other Search Engine
SVG/WTS
Mailer
Telemarketing
Other
Referral Source Name
*
Please describe what's going on with your claim
Additional Contact
Contact Name
First
Last
Contact Phone
Contact Phone Type
Mobile
Home
Office
Fax
Contact Text Permission
Yes
No
Contact Email
Is this person an Additional Insured?
No
Yes
Insurance Information
Insurance Company
*
Policy Number
Claim Number
*
Cause of Loss
*
Storm (Hail/Wind)
Weight of Ice/Snow
Water
Fire
Lightning
Tornado
Smoke
Flood
Theft
Vandalism
Other
Date of Loss
MM slash DD slash YYYY
When did you file your claim?
MM slash DD slash YYYY
Insurance Adjuster, Supervisor, or Carrier's Appraiser Contact
Who have you talked to?
Insurance Adjuster
Carrier's Appraiser
I don't know
No one
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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Phone
This field is for validation purposes and should be left unchanged.
Address
609 S. Kelly, Ste. F-3, Edmond, OK 73003
SEE MAP
Phone
Main Office:
(855) 45-CLAIM
CALL US NOW
Email
claims@coppermark.claims
EMAIL US
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