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Confirmation of Completed Repairs
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What is your first name? *
*
What is your first name? *
What is your last name? *
*
What is your last name? *
What is your email address? *
*
What is your email address? *
What is your phone number? *
*
What is your phone number? *
What type of claim did you have? *
*
What type of claim did you have? *
Homeowners
Automobile
Valuable Articles
Watercraft
Recreational Vehicle
What type of homeowners claim did you have?
What type of homeowners claim did you have?
Wind/Hail
Water
Did you repair/replace the damage?
Did you repair/replace the damage?
Yes
No
What date did the repair/replacement take place?
What date did the repair/replacement take place?
MM slash DD slash YYYY
Contractor Information
Please provide name and contact information for your contractor.
What is your contractor's name?
What is your contractor's name?
What is your contractor's phone number?
What is your contractor's phone number?
What is your contractor's email?
What is your contractor's email?
What type of material was used for the replacement?
What type of material was used for the replacement?
Wood
Asphalt
Metal
Please select the type of asphalt shingles that were used in the repair/replacement.
Please select the type of asphalt shingles that were used in the repair/replacement.
UL 2218
Please upload documentation showing evidence of the repair/replacement.
Please upload documentation showing evidence of the repair/replacement.
Drop files here or
Select files
Max. file size: 5 MB.
Has the water damage been repaired?
Has the water damage been repaired?
Yes
No
Did you install an automatic water shutoff valve device?
Did you install an automatic water shutoff valve device?
Yes
No
Please upload documentation confirming the purchase and installation of the device.
Please upload documentation confirming the purchase and installation of the device.
Drop files here or
Select files
Max. file size: 5 MB.
Many insurance companies are making the installation of an automatic water shutoff valve a requirement for renewal eligibility. These devices are an effective solution to prevent major water damage at your home.
Was your vehicle totaled because of the accident?
Was your vehicle totaled because of the accident?
Yes
No
Have you replaced your vehicle?
Have you replaced your vehicle?
Yes
No
Please enter the vehicle information below.
Please enter the vehicle information below.
Year
Make
Model
Please select the correct option below.
Please select the correct option below.
I do not intend to replace the vehicle
I will contact my agent when I replace the vehicle
Was your watercraft totaled because of the accident?
Was your watercraft totaled because of the accident?
Yes
No
Have you replaced your watercraft?
Have you replaced your watercraft?
Yes
No
Please enter the watercraft information below.
Please enter the watercraft information below.
Year
Make
Model
Please select the correct option below.
Please select the correct option below.
I do not intend to replace the watercraft
I will contact my agent when I replace the watercraft
Was your recreational vehicle totaled because of the accident?
Was your vehicle totaled because of the accident?
Yes
No
Have you replaced your recreational vehicle?
Have you replaced your recreational vehicle?
Yes
No
Please enter the recreational vehicle information below.
Please enter the recreational vehicle information below.
Year
Make
Model
Please select the correct option below.
Please select the correct option below.
I do not intend to replace the recreational vehicle
I will contact my agent when I replace the recreational vehicle
Have you replaced the item?
Have you replaced the item?
Yes
No
Please upload an appraisal or bill of sale for the replacement item.
Please upload an appraisal or bill of sale for the replacement item.
Drop files here or
Select files
Max. file size: 5 MB.
Please select the correct option.
Please select the correct option.
I do not intend to replace the item
I will contact my agent when I replace the item
What mitigating steps will you take to prevent a similar future loss?
What mitigating steps will you take to prevent a similar future loss?
Please sign your name in the space below. *
*
Please sign your name in the space below. *
<font size="2" color="gray">Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
I agree*
Kurt Thoennessen, CAPI
(203) 405-2645
http://ajg.com/
kurt_thoennessen@ajg.com
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