Request for Housing

Please Fill Out Form to Request for Housing

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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

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 Description (how many, type, size?)

Damaged Residence Information

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Notes

Contact information

Rice Corporate Services
Nationwide Housing
Phone: 1 (888) 665-RICE (7423)
E-Mail: [email protected]