INSURANCE RESTORATION INTAKE

Tell Us About the Loss.

Use this form for fire, water, storm, impact and other insured property damage. The more information you provide, the faster our team can review the repair scope and documentation.

CLARK BUILDING & DEVELOPMENT GROUP

Insurance Claim & Restoration Intake

This intake gathers the information commonly needed to evaluate damage, prepare a construction repair estimate, document the loss and coordinate with your carrier or adjuster when you authorize us to do so.

480-995-31311301 E Washington St, Suite 103
Phoenix, AZ 85034Phoenix • Chandler • GilbertROC #349572

Emergency? If the property has active water intrusion, electrical hazards, fire damage, structural instability or another immediate safety issue, call 911 or the appropriate emergency service first.

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1. Property Owner / Insured

Property Owner / Insured NameBest Phone

EmailPreferred Contact Method

Damaged Property Address

CityZIP Code

Is this your primary residence?Property Type

Mailing Address, if different

2. Loss / Damage Information

Date of LossApproximate Time of Loss

Type of Loss What happened?

Is the source of damage stopped / repaired?Is the property currently safe to occupy?

Areas Affected (check all that apply)

3. Emergency / Mitigation Work

Emergency mitigation already performed?Who performed the mitigation?

Work already completed (check all that apply) Emergency / mitigation notes

4. Insurance Claim Information

Insurance CompanyPolicy Number

Claim NumberDeductible, if known

Has the claim been opened?Has coverage been confirmed?

Adjuster NameAdjuster Phone

Adjuster Email

Inspection already completed by carrier?Carrier Inspection Date

Has the insurance company issued an estimate or scope? Has any claim payment been issued? Mortgage / Lienholder Name, if shown on insurance payment

5. Repair Scope & Project Status

Are plans / engineering required or already available?Has another contractor provided an estimate?

Repairs you believe are needed

Desired Repair StartAre permits expected?

6. Documents & Photos Damage Photos / Videos / Documents (optional)

Helpful uploads include damage photos, carrier estimate/scope, mitigation documents, adjuster correspondence, engineering reports, roof reports, receipts and any existing repair estimates. Do not upload Social Security numbers, bank information, passwords or other unnecessary sensitive information.

7. Authorization & Additional Notes Additional Notes

Clark Building & Development Group is acting as a licensed contractor, not as a public adjuster or attorney. We prepare construction scopes/estimates and perform repairs. Insurance coverage, claim valuation and settlement decisions remain between the insured and the insurance carrier or appropriately licensed claim professional.

Our team will review your information and contact you about the next construction/restoration steps.