SUB-DRVTEST-859472-2
Sarah Mitchell· +13035554821·HO3-CO-004821(HO-3)
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SUB-DRVTEST-859472-2CLM-28264
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Claim Data
Everything captured about this loss. Amber values are live — extracted in-call before reconciliation. Confirm and override as needed.
Policy
- Policy #
- HO3-CO-004821
- Product
- HO-3
- Risk address
- 123 Aspen Lane, Denver, CO, 80202
Reporter
- Reporter name
- required
- Reporter phone
- required
- Reporter email
- —
Policy
- Policy number
- required
Loss details
- Type of claim
- —
- Cause of loss
- Water Damage
- Date of loss
- 2026-06-05
- Approximate time of loss
- —
- Loss address
- 123 Aspen Lane, Denver, CO, 80202
- What happened (caller narrative)
- Supply Line Under The Upstairs Bathroom Sink Failed Overnight. Water Ran Through The Ceiling Into The Living Room; Drywall, Flooring And Some Furniture Affected. House Is Still Liveable.
- Areas affected
- —
- Damage description
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- Property occupied at time of loss
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- Accident location
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- Citation issued (statute)
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- Adverse carrier claim number
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- Authorities called
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- Mitigation started
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- Occupied at loss
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- People injured
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Next Steps
- Payment method
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- Has contractor estimate
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- Callback number confirmed
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- Preferred follow-up channel
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- Best time to reach them
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- Has evidence to share
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Authorities
- Authorities involved
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- Police report number
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- Police agency
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- Fire report number
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- Fire department
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Business Income
- Average daily rate (ADR)
- —
- Occupancy rate (%)
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- Period of restoration — start
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- Period of restoration — end
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- Extra expense incurred
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Cause Fire
- Fire origin
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- Fire extinguished by
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- Smoke damage in unaffected rooms
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Cause Theft
- Point of entry
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- Items stolen
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- Serial numbers (if shared)
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Cause Water
- Water source
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- Water shut-off accessible
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- Mold visible
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- Pipe location
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- Leak repaired
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- Water on the floor
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- Room > 400 sq ft
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- Room/floor finished
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Cause Wind
- Roof age (years)
- —
- Shingle / roof type
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- Interior leaks visible
- —
Commercial intake
- Caller's role at the organization
- —
- Named insured (organization)
- —
- Financial contact name (GM/owner)
- —
- Financial contact email
- —
- Rooms / units out of service
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Damages
- Alleged cost of repair
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- Implicated trades
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- Buildings / units affected
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Employee
- Date of birth
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- SSN (last 4)
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- Date of hire
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- Occupation
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- Employment status
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Employment & wages
- WC class code
- —
- Employer FEIN
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- Employer NAICS
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- Employee preferred contact channel
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- Employee represented by counsel?
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- Attorney of record
- —
- Modified duty status
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- Modified duty task list
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- Wage continuation during modified duty
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- Base hourly rate
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- Scheduled hours per week
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- Overtime hours (52 wk)
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- Actual gross earnings (52 wk)
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Estimate
- Repair facility
- —
- Repair facility phone
- —
- Estimate number
- —
- Estimate date
- —
- Estimator
- —
- Estimate type
- —
- Parts subtotal
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- Labor subtotal
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- Materials subtotal
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- Estimate total
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- Supplement total
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- Revised total
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Fleet Vehicle
- Fleet unit number
- —
- Vehicle
- —
- VIN
- —
- Odometer at loss
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- Drivable after loss
- —
Injury
- Date of injury (DOI)
- required
- Time of injury
- —
- Date reported to employer
- —
- Date reported to claims administrator
- —
- Jurisdiction
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- Workplace address
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- Body part
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- Side (L/R/bilateral)
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- Nature of injury
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- Mechanism narrative
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- ICD-10 (primary)
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- ICD-10 (secondary)
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- Cause narrative
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- Written work restrictions
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- Restrictions effective date
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- Restrictions estimated duration (weeks)
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- Restrictions reassessment trigger
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Inspection report
- Inspection completed at
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- Inspection findings summary
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- Replacement cost value (RCV)
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- Actual cash value (ACV)
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- Recoverable depreciation
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- Net ACV payable now
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Liability
- Police report status
- —
- Disputed liability facts
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- Agent-filed FNOL
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Litigation
- Court
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- Case number
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- Date complaint filed
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- Date served
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- Responsive pleading due
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- Causes of action
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- Claimant
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- Plaintiff counsel
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- Civ. Code § 910 (SB800) notice — date served
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Mitigation
- Mitigation started
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- Mitigation vendor
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- Mitigation vendor phone
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- Contractor engaged
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- Contractor
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- Contractor phone
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- Preferred cleanup vendor
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Mitigation invoice
- Mitigation invoice vendor
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- Mitigation invoice total
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- Mitigation invoice date
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- Mitigation invoice number
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- Mitigation invoice balance due
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- Mitigation service start
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- Mitigation service completion
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Other
- Estimated amount
- —
- Best callback window
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People & witnesses
- Injuries reported
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- Injury summary
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- Witnesses
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Program
- Client approval status
- —
- Client approved on
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Project
- Project name
- —
- Project address
- —
- Insured's role on the project
- —
- Property type
- —
- Number of units
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Property Condition
- Displaced from property
- —
- Where they're staying now
- —
- Displaced since
- —
- Water shut off
- —
- Power shut off
- —
- Gas shut off
- —
- Prior claims at this property
- —
- Rooms affected
- —
- Floors affected
- —
- Opening to the outside
- —
Provider
- MPN status
- —
- Specialty
- —
Rental
- Rental reservation
- —
- Rental daily rate
- —
- Rental days
- —
- Rental total
- —
- Rental return date
- —
Repair
- Repair shop
- —
- Estimate number
- —
- Original estimate total
- —
- Days to repair (DTR)
- —
- Projected completion date
- —
- Supplement 1 — delta
- —
- Revised repair total
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- Final invoice total
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- Repair completed
- —
- Drop-off scheduled
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- Drop-off reschedule requested
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Repairs
- Body shop chosen
- —
- Body shop name
- —
Risk transfer
- Trade
- —
- Subcontract requires additional insured status?
- —
- Indemnity clause type
- —
- COI deficiencies
- —
- COI policy period
- —
- COI certificate holder
- —
Statutory clocks
- MPN ID
- —
Coverage trigger
- Date of substantial completion
- —
- Notice of Completion — recorded date
- —
- Alleged manifestation date
- —
- Potentially triggered policy years
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- Other liability coverage in the trigger window
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Vehicle
- Vehicle year
- required
- Vehicle make
- required
- Vehicle model
- required
- Drivable status
- required
- VIN
- —
- License plate
- —
Communication Hub
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Sarah Mitchell
+13035554821 · sarah.mitchell@email.comPrefers voice
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