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☎ (303) 317-5349

Home

About

Contact

Comments

☎ (303) 317-5349

New Assignment Intake Form

Public Insurance Adjuster Client Intake Form

Please complete this short intake so we can open your claim file. Questions? office@dencocc.com • (303) 317-5349

Do not fill:

Full Name(s)*

Email*

Primary Phone*

Secondary Phone

Property Address (Claim Location)*

Mailing Address (if different)

Preferred Method of Contact

Phone Email Text Other

Best Time(s) to Contact You

Mortgage & Financial Interest

Current Mortgage Company / Lender*

Loan Number*

Mortgage Mailing Address (if known)

Mortgage Contact (if known)

Mortgage Phone/Email (if known)

Additional Financial Interests?

2nd Mortgage HELOC Lienholder HOA / Management

Details for Additional Financial Interests

Property & Repair History

Any repairs/maintenance since the date of loss?

Yes No

Type of Work Completed

Date Work Completed

Contractor / Company Name

Contractor Phone / Email

Was this work related to the insurance claim?

Yes No

Contractor Preference

Do you have a preferred contractor?

Yes No

Company Name

Primary Contact

Phone / Email

Claim Details

Policy Number

Date of Loss (if known)

Type of Loss

Has an insurance claim already been filed?

Yes No

Insurance Carrier

Claim Number

Assigned Adjuster (if known)

Adjuster Phone (if known)

Adjuster Email (if known)

Have you received a claim estimate or payment?

Yes No

Upload estimate/photos (optional)

You can also email documents to office@dencocc.com.

Authorizations & Notices

I authorize DENCO Claims Consulting LLC to communicate directly with my contractor regarding this claim.

I agree to receive texts related to my claim. Msg & data rates may apply. You can opt out anytime.

I have read and agree to DENCO’s Privacy Notice and understand my information will be used for claim handling.

Questions? (303) 317-5349 • office@dencocc.com

By submitting, you authorize DENCO to review the information provided and contact you about your claim.

Proud Member of the Rocky Mountain Association of Public Insurance Adjusters, the National Association of Public Insurance Adjusters, the American Association of Public Insurance Adjusters, and the Insurance Appraisal & Umpire Association.

Proud Sponsor of United Policyholders.