Personal Insurance Claim Feedback Form

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?

Claim Information

What type of insurance claim did you recently have?*

What type of insurance claim did you recently have?

How did you report the claim to the insurance company?*

How did you report the claim to the insurance company?

Call to my agent
Call to the insurance company
Email to my agent
Insurance company website
Agency website
Text to my agent
Visited my agent's office

Were you satisfied with the responsiveness of your insurance company to your claim?

Did the insurance company's claims adjuster provide a clear understanding of the claims process?

Yes
No

Was your claim settled in an acceptable timeframe?

Yes
No

How satisfied are you with how your agent/agency handled your claim?

What is the name of the agent who assisted you?

Please provide a brief description of the assistance you received from the agent/agency.

Did the policy coverage match your expectations as outlined to you by your agent/broker when your policy was written?

Yes
No

Please provide a brief explanation about how your coverage program did not meet your expectations.

How satisfied are you with how your insurance company handled your claim?

Please feel free to provide further details about your claims experience below.

How satisfied are you with the final claim settlement?

How would you rate your overall satisfaction with the handling of your claim?

Policy Credit Identification

Complete this section to help identify policy credits that you might be eligible for because of the repairs and work done to your home during this claim.

Did any of the following take place as part of this claim? (Select all that apply)

Roof Repair/Replacement
Installed Automatic Water Shutoff Device
Installed Standby Backup Generator
Elevated House
No

Roof Repair Information

What percentage of the roof was repaired/replaced?*

What percentage of the roof was repaired/replaced?

100% Full Replacement
50% or more
Less than 50%

Please provide a brief explanation why the roof was not fully replaced.*

Please provide a brief explanation why the roof was not fully replaced.

Please select your roof type.

Does your roof have a specific UL (Underwriting Laboratories) rating?*

Does your roof have a specific UL (Underwriting Laboratories) rating?

Yes
No
Not sure

Please enter the date the roof repair/replacement occurred.*

Please enter the date the roof repair/replacement occurred.

What is the name of the contractor?

Please enter the contractor's address.

Street Address Address Line 2 City State ZIP Code

Please enter the contractor's phone number.

Do you have a copy of your contractor's work estimate and/or invoice confirming the type of roof material and the date the replacement of the roof was completed?

Yes
No

Please upload a copy of the contractor's work estimate and/or invoice confirming the type of roof material and the date the replacement of the roof was completed.

Drop files here or

Max. file size: 128 MB.

Additional Remarks

Please enter any additional remarks you would like to share with us in the space below.

Personal Insurance Claim Feedback Form

Claim Information

Policy Credit Identification

Roof Repair Information

Additional Remarks

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Personal Insurance Claim Feedback Form

Claim Information

Policy Credit Identification

Roof Repair Information

Additional Remarks

Powered by RiskRevu

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter