Is this a home or business?HomeBusiness

Age of home:

Ever been remodeled?YesNo

What is the source of the water?

When did the loss occur?

Is there a basement?NoneSolidBlockCrawlConcrete SlabOther

Have you experienced a water loss before?YesNo

When?

Sewage or Fresh?SewageFresh

Has the area ever been wet before?YesNo

When?

Sewage or Fresh?SewageFresh

Was is mitigated?

Is there any visible discolorization, microbial growth or odor?

Is there any asbestos, lead or other hazardous materials present?

Have any of the following been affected? (check all that apply)

WaterbedsPool tablesAppliancesEntertainment centersGunsHi-fi equipmentCollectablesArt workBooksMagazinesPhotosDocumentsOriental/Specialty area rugsUpholstered furnitureComputersMattressesPianoOther (list below)

List other?

Is there electricity?YesNo

Is there water?YesNo

Is there an elevator?YesNo

Does it work?YesNo

How can we gain access?

DRYING EQUIPMENT

(all check boxes must be checked and agreed to)

DRYING EQUIPMENT CAN SAFELY RUN 24 HOURS A DAY.

DO NOT SHUT OFF DRYING EQUIPMENT. HIDDEN MOISTURE MAY CAUSE MOLD AND ODORS.

IF THE CIRCUIT BREAKER TRIPS, PLEASE RESET IT AND CALL US.

EQUIPMENT WILL BE NOISY.

TEMPERATURE

(all check boxes must be checked and agreed to)

EQUIPMENT WILL RAISE THE TEMPERATURE

PLEASE LET US CONTROL YOUR THERMOSTAT DURING THE DRYING PROCESS.

KEEP ALL DOORS AND WINDOWS CLOSED.

PLEASE DO NOT ENTER THE SEALED CONTAINMENT AREA.

ODORS

(all check boxes must be checked and agreed to)

SOME ODORS ARE NORMAL, PLEASE CALL IF YOU HAVE ANY SEVERE ODOR PROBLEMS.

JOB MONITORING

(all check boxes must be checked and agreed to)

WE WILL RETURN DAILY TO CHECK THE DRYING PROCESS.

NEED TO KNOW

(all check boxes must be checked and agreed to)

ANY RECONSTRUCTION WORK SHOULD NOT BE DONE UNTIL THE DRYING PROCESS IS COMPLETE.

YOUR CARPETS WILL BE CLEANED AFTER RECONSTRUCTION.

(optional)

DO YOU NEED ASSISTANCE IN FINDING A COMPANY FOR YOUR RESTORATION.

BILLING

(all check boxes must be checked and agreed to)

PAYMENT IS DUE UPON COMPLETION OF SERVICES.

WE WILL TAKE CARE OF THE INITIAL BILLING TO Y OUR INSURANCE COMPANY.

PLEASE KEEP CHILDREN AND PETS AWAY FROM THE WORK SITE. FLOORS MAY BE SLIPPERY AND STRUCTURAL ITEMS MAY BE SHARP OR HAZARDOUS.

Customer Signature:

Customer Name (Print):

Date: