Portal Intake Test

Internal test page. This is a copy of the contract submission form used to test the portal intake path. Submissions here do not create a real claim workflow and do not reach the usual automation. Please do not use it for a real client.

Policyholder Name(Required)

First Last

Additional Policyholder Name

First Last

Policyholder Email(Required)

Additional Policyholder Email

Policyholder Phone(Required)

Additional Policyholder Phone

What State is Loss Located?(Required)

Date of Loss(Required)

Adjuster(Required)

Address of Loss(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Name of Person Completing Form(Required)

First Last

Your Company Name

Your Phone

Your Email

Contractor Information

Company Name

Contractor Phone

Contractor Email

Referral Source if not Contractor

Source Email

Type of Loss(Required)

If Commercial Entity Name

Cause of Loss(Required)

Loss/Damage Description(Required)

What type of assignment?

If Supplement Dollar Amount Paid/Notes

Insurance Company(Required)

Policy Number(Required)

Status of Claim(Required)

Claim Number

File Upload

*Please make sure to upload your Declarations page of your policy for the date of loss or any previous/pertinent claim documentation for a more efficient onboarding*

Drop files here or

Max. file size: 256 MB.

Notes

By checking this optional box, you consent to receive recurring claim-related informational text messages (SMS/MMS) from Coastal Claims Services LLC at the mobile number provided. Consent is not a condition of service. Message frequency varies. Message and data rates may apply. Reply HELP for help or STOP to opt out.

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Portal Intake Test

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