EMS Form

EMS Form

Insured's Information

First Name First name is required.	Last Name Last Name is required.	Email Invalid email address!
Phone Number Phone Number is required.		Secondary Phone Number Invalid Phone Number

Address Address is required.	Project Type Project Type is required.
County County is required.
Claim Number
Severity Level Severity Level is required.

Wind 1 - No information available, insured has not seen the house, but knows there is damage. Needs FEMA letter only. Loss of Use only. Food spoilage only.

Wind 2 - Minimal damage to detached structures, contents damage only, some damage to roof.

Wind 3 - Damage to roof, missing shingles/tiles/metal with some interior water damage, but dwelling is still livable.

Wind 4 - Heavy structural damage to roof, framing, with heavy interior water damage, collapsed walls, ceilings. Dwelling is not livable or dwelling is a total loss.

Additional Details

Claim Type Claim Type is required.

The forms in this system are outdated, and a new system is in place - if you do not already have them, please refer to your manager in regards to the new updated links