Client Registration Form: Fill out the form and we contact you.

Client Registration Form

Please complete each section. If you have a copy of your policy or declarations page, or any photos or receipts , please email them to EQUITY@MOSAIC.CLAIMS If you have a paper document you are welcome to take a picture of it and email to us.

Do you have insurance?

Yes

No

Have you filed an insurance claim already?

Yes

No

How can we help you?

I have a question

I would like to schedule a free damage inspection.

I would like to hire Mosaic Claims Management to manage my claim(s), and need a contract.

Other

How did you hear about us?

Contractor

Facbook

Past or Current Client of Ours

Mitigation Company

Instagram

Other

Name of Policyholder 1

Name of Policyholder 2 (if applicable)

Phone Number

Email Address of Named Insured 1

Email Address of Named Insured 2

Loss Location

Street Address

City

State

Zip Code

On a scale of 1-6 where would you rate your damage?

Is your home/building livable (you can use a bathroom, kitchen, and have a place to sleep?)

Yes

No

Maybe

What is the square footage of your home/building?

Insurance Company's Name

Policy Number

Claim Number

Date of loss (if known)

Cause of Loss

Hurricane Ida

Hurricane Laura

Hurricane Delta

Fire

Wind

Hail

Water

Unknown

Other

Mortgage Company Name (if no mortgage, enter None)

Assigned Public Adjuster

David Kim

Unknown

Other

No adjuster assigned

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This form was created inside of Mosaic Claims Management