Agent Inspection Request
Lifetime strives to provide the best possible service to our Insurance Agency partners and their customers. Please complete this form with as much information as you can provide. It is okay if you are unable to fill out every field but the more we know, the better we can serve you. Thank you. If you have any questions you can always reach us at 314-800-0426
Email *
Agency Representative *
Name of the person submitting this request
Agency Name *
Name of your agency or brokerage
Who is to receive inspection results (if different from above)
Provide name and email address only if different from for submitter.
Insured Client Information
Property Owner First and Last Name *
Property Owner Phone Number *
Property Owner Email Address
Property Address *
Please provide full street address including city, state and zip
What is the approximate age of the roof?
Insurance Carrier Name *
When was this policy written?
If less then 2 years old
MM
/
DD
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YYYY
Wind/Hail Deductible amount
Is this a replacement cost policy?
Clear selection
Does this policy have Law and Ordinance coverage?
Clear selection
What stage of the claim process is this customer in?
When do they suspect the damage occurred?
To be confirmed or adjusted upon inspection results
MM
/
DD
/
YYYY
Please explain clients concerns or requests
A copy of your responses will be emailed to the address you provided.
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