Property & Auto Case Submission - Derrevere Stevens Black & Cozad

Referrer’s Contact Information

Referrer's Email Address*

Referring Individual’s Name*

Referring Company Name*

Phone Number*

Insured/Policyholder Information

Full Insured/Policyholder Name*

Address

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email Address*

New Loss Information

Underwriting Carrier Name*

Policy Number*

Claim Number*

Date of Loss

Loss Location*

Street Address Address Line 2 City State ZIP Code

Was an Expert Retained?*

Yes

Provide name and firm:*

Type of Loss – Check All That Apply

Property – Structural

Electrical Fire

Cooking Fire

HVAC-Related Fire

Faulty Wiring

Appliance Malfunction

Construction Defect – Roofing

Construction Defect – Plumbing

Structural Collapse

Building Code Violation

Property – Water

Frozen Pipe

Pipe Burst

Sewer Backup

Appliance Leak

Roof Leak

HVAC Condensation

Sprinkler System Malfunction

Property – Storm / Weather

Hail Damage

Wind Damage

Tree Impact

Ice Damming

Lightning Strike

Property – Miscellaneous

Theft/Burglary

Vandalism

Defective Product Caused Damage

Utility Company Negligence

Neighbor Negligence

Neighbor Tree Loss

Product Defect

Yes

Who is the Manufacturer?

Motor Vehicle Loss

Yes

Was a Police report taken?

Yes

Is Claim fully Adjusted?*

Yes

What was the indemnity?*

What was the deductible?*

Was the deductible waived?*

Yes

Brief Description of Loss:

Damages Paid (To Date)

Property

Contents

Additional Living Expenses

Business Property

Business – Lost Rent (Loss of Use) Paid

Adverse Party Information (if known)

Target(s)

Name of Attorney or PA

Firm Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

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Important Notice Regarding Case Referral Submissions

Submitting information through this online referral form does not establish an attorney-client relationship between you and DSB&C or any of our attorneys. Please do not include confidential or sensitive information in your submission until you have spoken directly with one of our attorneys and formally established a privileged attorney-client relationship.

If you are not presently a client of DSB&C, any information you provide through this form may not be protected by attorney-client privilege. This referral portal and our invitation to contact us should not be interpreted as a solicitation for legal services or as creating any attorney-client relationship. Additionally, this should not be construed as confirmation that our attorneys are available to provide legal representation in jurisdictions where they are not licensed to practice law.

By completing and submitting this referral form, you acknowledge that you have read, understood, and agree to these terms and conditions.

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