Homeowner Intake Form (Workato) Cohen Law Group. This is _____ speaking. To whom do I have the pleasure of speaking with? May I ask how to spell your first and last names?* First Last Thank you. What is the best phone number to reach you in case we lose connection?*Is this a cell phone number?YesNoWould you like to receive text messages to this number from us?YesNoWonderful! What email address is the best to communicate regarding this matter?* Thank you. Please - tell me what happened? (provide empathetic customer service) --- "we're are sorry that you have had to go through this" --- "I can understand this has been frustrating" What happened?Thank you. I have just a few more questions so I can provide as much detail to an attorney for review of your case. What is the address where the damage occurred? Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Damaged Property AddressWhen did you purchase the home?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Can you send me a copy of the purchase inspection?YesNoDo you reside at this address?YesNoWho owns the property with you? What is your current mailing address? Cur Street Add Cur Street Add2 Cur City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Cur State Cur ZIP What was the date that the damage occurred? MM slash DD slash YYYY Was there roof damage?YesNoDo you have flood damage?YesNoDo you have flood insurance?YesNoDo you have damage to the home’s interior? Or to personal property or contents (furniture, etc.)?YesNoDo you have damage to other structures like patio screens, fences or sheds?YesNoDid you incur additional living expenses, such as temporary housing, storage fees, meals?YesNoDid you incur out of pocket expenses?YesNoOut of pocket expenses - How much?Did you make a Hurricane Irma claim for your property?YesNoAre there any prior roof claims for this property?YesNoWho is your insurance company? Do you have your policy number? (enter policy number) Has a claim been filed?YesNoWhat is the claim number? Do you have an estimate?YesNoWhat is the estimate amount?Thank you (name). What is your deductible amount?Did you receive any payment from (insurance company)?YesNoHow much did you receive from your insurance company?Did you receive a letter from your insurance company denying your claim?YesNoCan you provide us a copy of the letter?YesNoHave you ever worked with a public adjuster or another attorney for this claim? Public Adjuster Enter PA name Prior Attorney Prior Attorney Enter attorney name Thank you. Just a few more questions to be sure we have all the information needed. Is there a mortgage on the property?YesNoWho is your mortgage with? Great! Is the payment status current?YesNoAre you working with any company to complete repairs?YesNoWhat is the name of the company? Enter Sales Rep Name Enter Sales Rep Contact Information: Have the repairs been completed or is there still damage?CompletedStill DamagedDo we have your permission to discuss your property damage claim with the contractor and ask them for documents and information?YesNoDid you sign an assignment of benefits?YesNoThank you (name) for providing all of this information. How did you hear about Cohen Law Group and how we can help you?*UnknownAdjusterBillboardCLG Attorney ReferralCLG StaffCLG WebsiteContractor ReferralCurrent or Former Client ReferralEventExternal Attorney or Associating AttorneyGoogle AdGoogle ReviewsProfessional ReferralYellow PagesYelp ReviewsWalk-inThe next step will be to take this information and have an attorney review and advise. I will be back in touch with you by end of day tomorrow with an update. To confirm your phone number is (confirm number) and your email address is (confirm email). Thank you (name of prospect) is there anything else I can do for you at the moment? Close out call.The next step I will email you a link to electronically sign our representation documents. Your email address is (confirm email) correct? Great! Once you sign and return the agreement we can assign the file to an attorney and start moving on your case.Are you near a computer or device that we can do through the documents together now?YesNoNot a problem. I am sending you the email now. Please call with any questions as you review the documents. We will be happy to help, I will follow up with you by end of day tomorrow. To confirm your phone number is (phone number). Thank you (name of prospect) - is there anything else I can do for you at the moment? Close out call.Walk them through and sign them up.(HVC INTERNAL) INTAKE ASSISTANT / CASE MANAGER*Angeles AquileraBetsy RodriguezDestiny WilliamsJewel McclellenLaura AndersonLaura PoormanLawanda WynnShawnelle KarpenSherryl LopezShirley GocoSophia BocquetVictoria BocquetViviana ZelayaZurayma FloresHidden(HVC INTERNAL) LEAD ATTORNEY: Hidden(HVC INTERNAL) LOCATION: Florida MATTER CASE TYPE:Unknownherein stated cause of lossBreak-In or TheftFire or LightningHurricaneWater DamageWind and/or Hail
