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 address *
Agency Representative *
Name of the person submitting this request
Your answer
Agency Name *
Name of your agency or brokerage
Your answer
Who is to receive inspection results (if different from above)
Provide name and email address only if different from for submitter.
Your answer
Insured Client Information
Property Owner First and Last Name *
Your answer
Property Owner Phone Number *
Your answer
Property Owner Email Address
Your answer
Property Address *
Please provide full street address including city, state and zip
Your answer
What is the approximate age of the roof?
Your answer
Insurance Carrier Name *
Your answer
When was this policy written?
If less then 2 years old
MM
/
DD
/
YYYY
Wind/Hail Deductible amount
Your answer
Is this a replacement cost policy?
Does this policy have Law and Ordinance coverage?
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
Your answer
A copy of your responses will be emailed to the address you provided.
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