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[contact-form to=”michael@jtlegalgroup.com,suro@jtlegalgroup.com,justine@jtlegalgroup.com,jeanette@jtlegalgroup.com” subject=”La Tuna Fire”]
[contact-field label=”Name of Client” type=”name” required=”1″]
[contact-field label=”Address” type=”textarea” required=”1″]
[contact-field label=”Number of Rooms” type=”text”]
[contact-field label=”Inside Sq. Ft.” type=”text”]
[contact-field label=”Outside Sq. Ft. ” type=”text”]
[contact-field label=”Visible Soot or Ash?” type=”select” options=”yes,no”]
[contact-field label=”Any damage to walls?” type=”select” options=”yes,no”]
[contact-field label=”Visible Soot or Ash?” type=”select” options=”yes,no”]
[contact-field label=”Any Damage to Walls?” type=”select” options=”yes,no”]
[contact-field label=”In which rooms?” type=”text”]
[contact-field label=”Was attick checked?” type=”select” options=”yes,no”]
[contact-field label=”Was pool checked?” type=”select” options=”yes,no,na”]
[contact-field label=”Was roof checked?” type=”select” options=”yes,no”]
[contact-field label=”Was entire property searched for ash damage?” type=”select” options=”yes,no”]
[contact-field label=”Was every room measured?” type=”select” options=”yes,no”]
[contact-field label=”How many A/C Registers?” type=”select” options=”1,2,3,4,5,6,7,8,9″]
[contact-field label=”How many air Returns?” type=”select” options=”1,2,3,4,5,6,7,8,9″]
[contact-field label=”Is there a duct?” type=”select” options=”yes,no”]
[contact-field label=”Is there a furnace?” type=”select” options=”yes,no”]
[contact-field label=”Damage to personal property?” type=”select” options=”yes,no”]
[contact-field label=”Failure by inspector?” type=”select” options=”yes,no”]
[contact-field label=”Living Room Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Dining Room Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Entry Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Hallway Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bedroom 1 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bedroom 2 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bedroom 3 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bedroom 4 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bathroom 1 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bathroom 2 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Bathroom 3 Contents?” type=”select” options=”light,medium,heavy”]
[contact-field label=”Adjuster Name” type=”name” required=”1″]
[contact-field label=”Adjuster Telephone No.” type=”text”]
[contact-field label=”Adjuster Fax No.” type=”text”]
[contact-field label=”Insurance Company” type=”text”]
[contact-field label=”Claim No.” type=”text”]
[contact-field label=”Date” type=”text”]
[contact-field label=”Time” type=”text”]
[contact-field label=”Rep Name” type=”text”]
[contact-field label=”Additional Comments” type=”textarea”]
[/contact-form]