www.temporaryhousingdirectory.com Open in urlscan Pro
192.252.149.17  Public Scan

Submitted URL: https://pages.temporaryhousingdirectory.com/ins-referral
Effective URL: https://www.temporaryhousingdirectory.com/forms/ins-referral/
Submission: On January 20 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://forms.hsforms.com/submissions/v3/public/submit/formsnext/multipart/9454818/73e69b7d-beb2-461e-9b1d-089b65ef973b

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  <div class="hs_firstname hs-firstname hs-fieldtype-text field hs-form-field"><label id="label-firstname-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Sender's Name (first and last)"
      for="firstname-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Sender's Name (first and last)</span><span class="hs-form-required">*</span></label>
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  <div class="hs_email hs-email hs-fieldtype-text field hs-form-field"><label id="label-email-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Sender's Email Address"
      for="email-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Sender's Email Address</span><span class="hs-form-required">*</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="email-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="email" required="" placeholder="" type="email" class="hs-input" inputmode="email" autocomplete="email" value=""></div>
  </div>
  <div class="hs_adjusters_name hs-adjusters_name hs-fieldtype-text field hs-form-field"><label id="label-adjusters_name-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Adjusters Name (if different from above)"
      for="adjusters_name-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Adjusters Name (if different from above)</span><span class="hs-form-required">*</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="adjusters_name-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="adjusters_name" required="" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
  </div>
  <div class="hs_phone hs-phone hs-fieldtype-phonenumber field hs-form-field"><label id="label-phone-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Adjuster's Direct Phone Number"
      for="phone-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Adjuster's Direct Phone Number</span><span class="hs-form-required">*</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="phone-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="phone" required="" placeholder="" type="tel" class="hs-input" inputmode="tel" autocomplete="tel" value=""></div>
  </div>
  <div class="hs_insurance_carrier_name hs-insurance_carrier_name hs-fieldtype-text field hs-form-field"><label id="label-insurance_carrier_name-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Insurance Carrier Name"
      for="insurance_carrier_name-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Insurance Carrier Name</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="insurance_carrier_name-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="insurance_carrier_name" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
  </div>
  <div class="hs_claim_number hs-claim_number hs-fieldtype-text field hs-form-field"><label id="label-claim_number-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Claim Number"
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="claim_number-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="claim_number" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
  </div>
  <div class="hs_date_of_loss hs-date_of_loss hs-fieldtype-text field hs-form-field"><label id="label-date_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Date of Loss"
      for="date_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Date of Loss</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="date_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="date_of_loss" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
  </div>
  <div class="hs_type_of_loss hs-type_of_loss hs-fieldtype-text field hs-form-field"><label id="label-type_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Type of Loss"
      for="type_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Type of Loss</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="type_of_loss-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="type_of_loss" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="insured_s_name__first_last_-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="insured_s_name__first_last_" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><textarea id="insured_s_full_address-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-input" name="insured_s_full_address" placeholder=""></textarea></div>
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  <div class="hs_insured_s_contact_information hs-insured_s_contact_information hs-fieldtype-text field hs-form-field"><label id="label-insured_s_contact_information-73e69b7d-beb2-461e-9b1d-089b65ef973b" class=""
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="insured_s_contact_information-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="insured_s_contact_information" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="number_of_occupants-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="number_of_occupants" placeholder="" type="number" class="hs-input" inputmode="tel" value=""></div>
  </div>
  <div class="hs_number_of_pets__if_none__enter_0_ hs-number_of_pets__if_none__enter_0_ hs-fieldtype-text field hs-form-field"><label id="label-number_of_pets__if_none__enter_0_-73e69b7d-beb2-461e-9b1d-089b65ef973b" class=""
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="number_of_pets__if_none__enter_0_-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="number_of_pets__if_none__enter_0_" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
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  <div class="hs_initial_approved_dates hs-initial_approved_dates hs-fieldtype-text field hs-form-field"><label id="label-initial_approved_dates-73e69b7d-beb2-461e-9b1d-089b65ef973b" class=""
      placeholder="Enter your Approval Period (enter start-end dates)" for="initial_approved_dates-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Approval Period (enter start-end dates)</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><input id="initial_approved_dates-73e69b7d-beb2-461e-9b1d-089b65ef973b" name="initial_approved_dates" placeholder="" type="text" class="hs-input" inputmode="text" value=""></div>
  </div>
  <div class="hs_hotel_or_housing hs-hotel_or_housing hs-fieldtype-select field hs-form-field"><label id="label-hotel_or_housing-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Indicate Hotel or Housing (or both)"
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><select id="hotel_or_housing-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-input is-placeholder" name="hotel_or_housing">
        <option disabled="" value="">Please Select</option>
        <option value="Hotel">Hotel</option>
        <option value="Housing">Housing</option>
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  </div>
  <div class="hs_parking_approved_ hs-parking_approved_ hs-fieldtype-checkbox field hs-form-field"><label id="label-parking_approved_-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Parking approved?"
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    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input">
      <ul role="checkbox" class="inputs-list multi-container">
        <li class="hs-form-checkbox" role="checkbox"><label for="parking_approved_0-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-form-checkbox-display"><input id="parking_approved_0-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-input"
              type="checkbox" name="parking_approved_" value="Yes"><span>Yes</span></label></li>
        <li class="hs-form-checkbox" role="checkbox"><label for="parking_approved_1-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-form-checkbox-display"><input id="parking_approved_1-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-input"
              type="checkbox" name="parking_approved_" value="No"><span>No</span></label></li>
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    </div>
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  <div class="hs_other_notes hs-other_notes hs-fieldtype-textarea field hs-form-field"><label id="label-other_notes-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="" placeholder="Enter your Other Helpful Notes?"
      for="other_notes-73e69b7d-beb2-461e-9b1d-089b65ef973b"><span>Other Helpful Notes?</span></label>
    <legend class="hs-field-desc" style="display: none;"></legend>
    <div class="input"><textarea id="other_notes-73e69b7d-beb2-461e-9b1d-089b65ef973b" class="hs-input" name="other_notes" placeholder=""></textarea></div>
  </div>
  <div class="hs_submit hs-submit">
    <div class="hs-field-desc" style="display: none;"></div>
    <div class="actions"><input type="submit" class="hs-button primary large" value="Submit"></div>
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NEW REFERRAL SUBMISSION FORM


Sender's Name (first and last)*

Sender's Email Address*

Adjusters Name (if different from above)*

Adjuster's Direct Phone Number*

Insurance Carrier Name

Claim Number

Date of Loss

Type of Loss

Insured's Name (First last)

Insured's Full Address

Insured's Contact Information

Number of Occupants

Number of pets (if none, enter 0)

Approval Period (enter start-end dates)

Indicate Hotel or Housing (or both)
Please SelectHotelHousing
Parking approved?
 * Yes
 * No

Other Helpful Notes?




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