Agreement Request Form Loss Report Number OR Name & City Solicitor(Required) blair@aipnw.com christine@greenspan-adjusters.ca david@aipnw.com dow@greenspan-ai.com dow@aipnw.com grant@greenspan-ai.com jessica@greenspan-ai.com ken@greenspan-ai.com ken@aipnw.com ken@greatplainasai.com ken@greenspan-adjusters.ca kenny.taylor@greenspan-ai.com max@greenspan-ai.com richard@greenspan-ai.com richard@aipnw.com rino@greenspan-ai.com rino@aipnw.com robertc@aipnw.com steve@greenspan-ai.com Name Insured(Required) Percent(Required)What is the agreed upon percentage fee?Type of Agreement(Required) Residential Commercial HOA Brand / Region(Required)TGC - San FranciscoTGC - SacramentoTGC - FresnoTGC - San JoseTGC - PleasantonTGC - AZTGC - New MexicoTGC - NevadaTGC - Idaho / Montana / WyomingAIPNW - WashingtonAIPNW - OregonAIPNW - AlaskaAIPNW - UtahGAI - British ColumbiaOtherIf other...write brand/region below Docusign or Email PDF?(Required) Send Via Docusign Send PDF - Client will Print & Sign EmailWhere are we sending this agreement? Does name insured match name of signee(s)?YesNo - Need to add name(s)Signee #1 First Last Email #1 Signee #2 (if any) First Last Email #2 Loss TypeFireWater DamageWind StormCollapseVandalismEarthquakeLoss Date MM slash DD slash YYYY Insurance Company Insurance Policy Claim Number (not required) Cancellation PolicyDefault is 3 business days. Specify if it needs to be changed or added in addendum. Maximum is 5 business days. Relevant Insurance FilesUpload files here, or email immediate needs if that is easier from your device. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 8 MB, Max. files: 5. Addendums Needed?No, not needed.Yes, please call me for details.Any Additional Notes?CAPTCHAUntitled EmailThis field is for validation purposes and should be left unchanged.