EstiPay
Customer Intake Form
Basic Details
Company Name
*
Company Website
*
Contact Name
*
Contact Phone Number
*
Contact Email Address
*
Number of Employees
*
Location Details
State
*
Primary Service Offered
*
Water Mitigation
Mold Remediation
Contents Handling
Reconstruction / Repairs
Fire / Smoke Restoration
Remove Storm / Catastrophe
Roofing
Other
Average Monthly Claims Processed
*
1 - 2
11 - 25
25 - 50
50+
Primary Goal for This Pilot
*
Faster Estimate Approval
Faster Carrier Payments
Reduced Admin Workload
Better Documentation Trail
Carrier / Adjuster Accountability
Submit
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