New Housing Request

Claimant and Adjuster Information

You may fax, phone, or use this form to email your request.
We will contact you 10 to 14 days before the end of each rental term.

Adjuster	Information
*Name:
*Insurance Company:
Independent Adjusting Company:
Business Phone:
Cell Phone:
Email Address:
Fax:
Business	Address
Street Address:
City:
State:
Zip Code:
I prefer to be contacted by:	Phone Email Fax
	Contact this family, move them in and send me your payment request. Contact this family, find a place for them and contact me for approval. Contact me for instructions on this loss. Contact me by phone on this loss.
Claimant	Information
Name:
Spouse's Name:
Claim Number:
Date of Loss:
Claimant's	Address
Street Address:
City:
State:
Zip Code:
Number of Adults:
Number of Children:
Insured Value:
Type of Damage:
Time to start*:
Total Likely Time Needed*:
*It helps us to	negotiate with our landlords if you can estimate total time needed.
Where are claimants now?:
Claimant Contact Number 1:
Claimant Contact Number 2:
Is a Hotel Stay Needed?:	Yes No
Limit:
Is there a Public Adjustor on this Loss?:	Yes No
Comments:
Advise us of the	Insurer's Payment Policies
	The insurer will honor the payment request in your Service Agreement and payments for rent will be sent in a one party check to your company.
	The insurer will not honor the request in your Service Agreement for a security deposit without a separate request for this advance signed by the claimant. Funds will be sent to your company offices.
	The insurer will only advance funds for a deposit to the claimant as an advance against their final settlement and these funds will be sent to them.
	The insurer takes no responsibility for payments to Temporary Housing Inc. for the housing of our claimant. The insurer sends all payments to our claimant.
	The Public Adjuster on this loss has no part of the A.L.E. settlement. We will pay as above.
	There is a Public Adjusting Company on this loss. You must get a signed release from that company before we can pay Temporary Housing Inc. directly on this loss.
	The Insurer will make no commitment for housing payments on this loss.

New Housing Request

Claimant and Adjuster Information

Adjuster

Information

Business

Address

Claimant

Information

Claimant's

Address

If there is something unusual about this loss, contact us by phone at (313) 538-5900