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Hanover Referral Form
LEAD_SOURCE
Required Installation*
-None-
YES
NO
First*
Last*
Email
Phone
Mobile
Relationship to Policyholder*
Policyholder
Insurance Agent
Business Agent
Property Manager
Personal Assistant
General Contractor
Plumber
Family Member
Street Address*
City*
State / Province / Region*
ZIP / Postal Code*
US/CA*
-None-
United States
Canada
Austria
Bahamas
Colombia
Costa Rica
England
France
Germany
India
South Africa
South Korea (Republic of)
Other
Rep Email
-None-
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Role
-None-
Claims Adjuster
Claims Rep
Risk Consultant
Policy Number*
Lead Type*
-None-
Pre-Loss
Post-Loss
Type of Loss (if applicable)
-None-
Water Damage
SUMP Pump
Primary Cause of Damage (if applicable)
-None-
Pipe failure
Appliance failure or supply line break
Plumbing fixture leak or malfunction
Flooding due to blockage or backup
Human error
SUMP-Primary Pump Failure
SUMP-Primary & Secondary Pump Failure
SUMP-Loss of Power (no battery backup)
SUMP-Insufficient Backup Power
SUMP-Too much water
SUMP-Drain backed up
Other:
Claim Number (if applicable)
SUMP Failure (if applicable)
-None-
Primary & Secondary pump failure
Loss of Power (no battery backup)
Insufficient backup power
Too much water
Drain backed up
Primary pump failure
Qualify for the leak prevention benefit?
-None-
Yes
No
Not Sure
Benefit amount is
-None-
$2500
Hanover Representative*
Description
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