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Berkley-One Referral
Berkley-One Referral Form
LEAD_SOURCE
Last Name*
First Name
Required Installation*
-None-
YES
NO
Relationship to Policyholder*
-None-
Business Agent
Family Member
General Contractor
Insurance Agent
Personal Assistant
Plumber
Policyholder
Property Manager
Risk Manager
Restoration Company
Wholesaler
Email
Phone
Mobile
Street
City
State
Zip Code
US/CA*
-None-
United States
Canada
Austria
Bahamas
Colombia
Costa Rica
England
France
Germany
India
South Africa
South Korea (Republic of)
Other
Lead Type*
-None-
Pre-Loss
Post-Loss
Policy Number
Claim Number
Primary Cause of Damage
-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:
Qualify for the leak prevention benefit?
-None-
Yes
No
Not Sure
Benefit amount
-None-
$1500 towards Labor and Leak Defense System
$2500 towards Labor and Leak Defense System
$5000 towards Labor ONLY
$5000 towards Labor and Leak Defense System
Berkley One Reps
-None-
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Carrier Representative*
Description
Please click the Submit button once. The submission may take a couple of minutes to complete.