Customer Information Form



Is this a home or business?

Age of home:

Ever been remodeled?

What is the source of the water?

When did the loss occur?

Is there a basement?

Have you experienced a water loss before?

When?

Sewage or Fresh?

Has the area ever been wet before?

When?

Sewage or Fresh?

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)

List other?

Is there electricity?

Is there water?

Is there an elevator?

Does it work?

How can we gain access?



DRYING EQUIPMENT

(all check boxes must be checked and agreed to)

TEMPERATURE

(all check boxes must be checked and agreed to)

ODORS

(all check boxes must be checked and agreed to)

JOB MONITORING

(all check boxes must be checked and agreed to)

NEED TO KNOW

(all check boxes must be checked and agreed to)

(optional)

BILLING

(all check boxes must be checked and agreed to)

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: