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Letter of
Representation

Complete this form to authorize Bear Claims Consulting Group to represent you in your property insurance claim. All information is kept strictly confidential.

Homeowner Information

First Name *

Last Name *

Email Address *

Phone Number *

Homeowner's Initials *

Property Address

Street Address *

Address Line 2

City *

State *

ZIP Code *

Insurance Policy Details

Is there a second person on the insurance policy? *

You can find this on your insurance policy's declarations page or by calling your insurance company.

NoYes

Insurance Policy Number *

Found on your declarations page or by calling your insurer.

Insurance Company *

How long have you had your current insurance company? *

Claim Details

Have you ever filed an insurance claim for the roof at this property? *

NoYes

Claim Number

If you have already filed a claim, add the claim number. If not, leave blank.

Date of Loss *

Cause of Loss *

Description of Loss *

e.g. "Roof damage" or "Roof damage with leaks inside the home"

Fee & Referral Information

Public Adjusting Fee *

Referring Roofing Company & Sales Rep *

If referred by a roofing contractor, include company name and sales rep.

Roofing Sales Rep Email *

This email will receive a copy of the signed LOR.

Documents

Upload Insurance Declarations Page & Roofing Contract

Upload a photo of your insurance declarations page. If you have a roofing contract, include it as well. Max 128 MB.

PDF, JPG, PNG, DOC accepted

Consent

I consent to receive SMS and email communications from Bear Claims Consulting Group at the phone number and email address I provided. Message frequency varies. Message & data rates may apply for SMS. Reply STOP to unsubscribe. For email, I may unsubscribe anytime using the unsubscribe link in each email. *

All information is kept strictly confidential and used only for claim representation purposes.

Letter ofRepresentation

Letter of
Representation