CORPORATE HOUSING REQUEST
INSURANCE ADJUSTER INFORMATION
Contact Name
Company
Address
City
State
Zip Code
Best Method of Contact (you may choose more than one method)
Pager Number
Fax Number
Cell Number
Email Address
Claim Information
Claim Number
Type of Loss
Length of Stay
Date of Loss
Value of Home
Homeowner Information
Name
Home Number
Work Number
Alternate Number 1
Alternate Number 2
Number of Adults
Number of Children
Pets Yes No
Description (how many, type, size, etc)
Damaged Residence Information
Notes
