ATTENTION
BUSINESS OWNERS

Has the COVID-19 crisis interrupted your business? If you have business insurance, let a lawyer review your policy, for free.

Call (866) 703-4878

COMPLETE THIS FORM

TELL US ABOUT YOURSELF
NAME*
YOUR EMAIL
PHONE
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
TELL US ABOUT THE BUSINESS
BUSINESS NAME
ADDRESS
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
What type of business?
Business Type
Do you own or rent the location of your business?
RENT OR OWN
- Rent
- Own
What is your relationship to the business?
What is your relationship to the business?*
- Owner
- Manager
- Other
What is your relationship to the business?
Was your business limited or shut down due to COVID-19?
Was your business subject to any state or local lock-down, stay at home, "shelter in place", or similar governmental order due to COVID-19?
- YES
- NO
Were you unable to receive supplies, services or customers due to COVID-19?
RECEIVESUPPLIES
- YES
- NO
What is the name of the insurance company that you have your Property or Business Owner's insurance policy from?
INSURANCE POLICY
Do you have Business Income Interruption Insurance?
INTERRUPTION INSURANCE
- YES
- NO
Have you submitted a claim to your insurer for lost income or business interruption due to a COVID-19?
SUBMITTEDCLAIM*
- YES
- NO
Has the insurer denied the claim or otherwise responded?
INSURANCE DENIED OR RESPONDED
- Yes
- No
- Not Applicable
To help us review your claim, please upload your :
Property or Business Owner's or insurance policy
Property or Business Owner's or insurance policy
Accepted file types: jpg, doc, pages, pdf, xls, docx.
Declaration page, Property or Business Owner's or insurance policy
Declaration page, Property or Business Owner's or insurance policy
Accepted file types: jpg, doc, pages, pdf, xls, docx.
Any claims correspondence you had with your insurance company or agent regarding your COVID-19 business interruption claim
Any claims correspondence you had with your insurance company or agent regarding your COVID-19 business interruption claim
Accepted file types: jpg, doc, pages, pdf, xls, docx.
Name
This field is for validation purposes and should be left unchanged.

If your insurance company has denied or disregarded your claim, we may be able to help.
You may still be eligible for money.

Please have the following
documents ready

Your business insurance policy
Your declarations page
Any attachments or riders associated with your insurance policy
Any notes or correspondence between you and your insurance company up to this point about this subject

BOCA RATON
1200 N FEDERAL HWY #200 BOCA RATON, FL 33432

BONITA SPRINGS
24799 RIVERVIEW CENTER BLVD, BONITA SPRINGS, FL 34134

Call (866) 703-4878

About Us

Scent however would go the they're himself a business good sure.

Usefull Links

Contact Details

Mon - Sat 8.00 - 18.00

Sunday CLOSED

youremail@.office.com

+0080 887 567 456

@qodeinteractive.com