Request for Housing Please Fill Out Form to Request for Housing Please Choose One Pleace Choose One Need Temporary Housing Fair Rental Value Assessment Hotel Accommodations Claim Representative Information Name* First Name Last Name Company* Company Name Address* Street Address Address Line 2 City State / Province / Region Zip / Post Code Best Method of Contact You may choose more than one method Street Address Cell Number Email Fax Number Claim Information Claim Number Date of Loss Type of Loss Value of Home Length of Stay Additiona Living Expenses (ALE) Homeowner Information First Name Last Name Home Number Work Number Other Number 1 Other Number 2 Number of Adults Number of Children Pets? Pets? Yes No Pets Description (how many, type, size?) Damaged Residence Information Street Address Address Line 2 City State / Province / Region Zip / Postal Code Country Country Notes Submit Contact informationRice Corporate ServicesNationwide HousingPhone: 1 (888) 665-RICE (7423)E-Mail: [email protected]