Quick Pay Claims App – Claim Submission

Subject Property

Take a landscape style (right to left) photo of the front of the subject property
Date of loss
MM slash DD slash YYYY
Loss Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Insurance company*
Claim number
How many rooms have water damage?*
Service charges and testing
Emergency Service
- Regular hours
- After hours
- No charge
Testing and clearances
Thermal imaging fee
Asbestos Fee
Mold Fee
Other fee
Monitoring Trips
Regular hours trips
After hours trips
Debris Disposal
Quantity of each
Pickup loads
Trailer loads
12 yard dumpsters
20 yard dumpsters
30 yard dumpsters
40 yard dumpsters
Equipment Usage
Regular drying fans
Days used
Axial drying fans
Days used
Dehumidifiers
Size
Number used
Days used
Wall-Injection
Total
Wall-Ducted
Total
Wood Floor Mats
Total
Write-in
Total
Negative Air –Avg
Total
Negative Air - Lg
Total
Room #1
Room Name*
Room Name if not on list
Room length
Room width
Room height
Offset #1 Name
Offset length
Offset width
Offset height
Offset #2 Name
Offset length
Offset width
Offset height
Offset #3 Name
Offset length
Offset width
Offset height
Photo 1 of wall left to right*
Photo 2 of wall continued*
Photo 3 of wall continued*
Photo 1 of ceiling*
Photo 2 of ceiling
Photo of floor
Room #2
Room Name*
#1*
#2*
#3*
#4*
#5*
#6*
Room #3
Room Name*
#1*

Take one photo of each different type
#2*
#3*
#4*
#5*
#6*
Photos 19-21 Additional Photos (Damage or access photos)
Open Item*
Open item*
Open item*
Write in description
Write in description
Write in description
Front Elevation Photos
Gutters*
Downspouts*
Fascia/Soffit*
Are the Front Elevations gutters damaged?
Are the Front Elevations downspouts damaged?
Is the fascia or soffit damaged?
If yes, how many linear feet?
If yes, how many linear feet?
If yes, how many linear feet?
What is the width of the overhang?

Save and Continue Later

Service charges and testing

Testing and clearances

Monitoring Trips

Debris Disposal

Equipment Usage

Room #1

Room #2

Room #3

Photos 19-21 Additional Photos (Damage or access photos)

Front Elevation Photos