Thank You For Submitting Your Information

In order to expedite your case please include the specified details below

Full name*

Email Address*

Phone Number

Check/move in and check/move out dates (MM/DD/YR format):*

Full address of where you encountered bed bugs:*

Date and time you realized you were bitten and date(s) others in your party realized they were bitten*

Did you or anyone observe bed bugs, blood on sheets, bed bug nests or bed bug fecal matter*

If yes, provide the date bed bugs or bed bug evidence were observed

Where did you see the bed bugs (ex. mattress, pillow, headboard,etc)*

If this occurred at a hotel, room number(s) and room switch dates*

Date you reported to the hotel, store and/or ownership*

Date(s) you and/or others in your party received medical treatment*

If applicable, explain any and all communication with the hotel, furniture store or apartment complex (include dates)

Name of each person bitten and the number of bites (indicate if someone is a minor)*

Did you speak to an insurance company for the property*

If yes, please provide the name of the insurance company

Did you report the incident to the department of health*

If yes, please provide the date