Via: INTERNET MAIL Ref Source: ESTABLISHED CLIENT
       
Carrier information:
Carrier:        Adjuster:
Phone:         Fax:          
Cell/Other: Email:       
Claim #: Deductible?
       
InstaClaim Preliminary Sheet
Pickup and store all salvagable items
Packout coverage included
Mitigate damage w/pre-clean or treat to store
Special handling items such as artwork, antiques, high value collectibles, etc…
Type of Damage:  Hold control key down and click to select multiple types.
     Onsite Inspection & Analysis with digital photo documentation ONLY.   Restoration and repairs pre-authorized (IF YES SUBMIT LIST & AMOUNTS PER ITEM VIA SEPARATE E-MAIL)
List items at right separated by a comma:
       
Insured Information
Coverage type: Full Flood Structure Contents (check all that apply)
Contents: Cabinetry or built-ins:    Water Remediation:
First name: Last name:
Address:           Phone:
City:

                         

 Cell:     
       
Insured will be contacted normally within 2-4 hours of receipt of this form during business hours to schedule initial inspection. If pre-authorizing repairs please submit separate list and authorized amounts.  We will schedule services to begin unless an item cannot be restored within the approved amounts in which case further approval for such item will be sought from the adjuster.  Items will be designated on a claim by claim, item by item basis by adjuster as follows:
     
 
1. Restore/Rebuild/repair to pre-loss.
  
 
2. Replace & dispose or possible salvage
  
 
3. Clean, treat, store, return to insured when possible.
  
 
In the case of natural disaster claims, flood, fire or police crime scene, as soon as physically possible, J.R. Polgar, Inc. or it's designee's will enter the areas and begin collection of items for processing and/or storage as the adjuster so designates. Items will be stored in our fully enclosed facility in the high area of Pinellas county (no evacuation) in designated sections for each claim.
       
  Proceed with the above selected services in accordance with our standard terms agreement with J.R. Polgar's:  
       
  Type Name Here:  
  Type Name AGAIN Here:  
     
 
Manually typing your name twice constitutes an electronic signature.
  
       
 
(click on the button below to initiate services)