Law Office of Nicholas M. Graphia, LLC
Property Insurance Claim Questionnaire
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Please click "I agree" to confirm that you realize the completion of this form does not create an attorney-client relationship. *
Required
Explain briefly what is going on with your insurance claim *
What is your name? *
What is your email address? *
What is your phone number and street address? *
When is the best time to call you? *
Required
Who is your insurance carrier? *
What is your policy number? Claim number?
What is your insurance agent's name and contact information?
What is your insurance adjuster's name and contact information?
How did your property damage occur? *
Hurricane, tornado, hail storm, or something else
Required
When did the damage occur *
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DD
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YYYY
When did you report the damage to your insurance carrier?
MM
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DD
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YYYY
When did the insurance company's representative come out to your property and investigate the damage?
MM
/
DD
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YYYY
How long was the representative at your property? *
Would you agree or disagree that your loss was thoroughly investigated? Please explain. *
Did the adjuster view all of the damages? *
How much money has your carrier paid on your claim to date? *
Did the payment include a 20% increase for overhead and profit? *
Which damages have been included in the payment and which damages have been left out? *
How much money do you believe you are owed on the claim? *
How long did it take to receive your payment from the insurance carrier? *
Did the carrier reimburse you for out-of-pocket expenses? *
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