HDI Reconnect Form V2

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This form is for HDI ONLY

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PO Number* This field is required.

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Com #* This field is required.If Com # is missing - please call office

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Customer Name* This field is required.

First Name

Last Name

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Plumbing Completed At* This field is required.NOTE: THE GEO-LOCATE BUTTON MAY NOT CAPTURE THE EXACT ADDRESS

Street Address

Street Address Line 2

City

State

Zip Code

Country

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The plumbing work completed at the address above has been photographed for quality assurance.

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How Many Basic (Separate) Reconnects Were Performed?* This field is required.A Basic Reconnect Includes: FAUCET, EXISTING DISHWASHER AIR GAP, EXISTING DISHWASHER DRAIN, GARBAGE DISPOSAL, P-TRAP, SUPPLY LINES

You will be asked in the following pages to provide details for each separate reconnect performed.

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First Reconnect - List What Was Reconnected* This field is required.Select OTHER and enter description if RC is not listed.

Faucet

Existing Dishwasher - Air Gap

Existing Dishwasher - Drain

Garbage Disposal

P-Trap

Supply Lines

Other

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New or Used Faucet?* This field is required.

NEW FAUCETUSED FAUCET

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New or Used Garbage Disposal?* This field is required.

NEW DISPOSALUSED DISPOSAL

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First Reconnect Notes* This field is required.Use this area to describe the reconnect. Be as detailed as possible.

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Second Reconnect - List What Was Reconnected* This field is required.Select OTHER and enter description if RC is not listed.

Faucet

Existing Dishwasher - Air Gap

Existing Dishwasher - Drain

Garbage Disposal

P-Trap

Supply Lines

Other

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New or Used Faucet?* This field is required.

NEW FAUCETUSED FAUCET

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New or Used Garbage Disposal?* This field is required.

NEW DISPOSALUSED DISPOSAL

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Second Reconnect Notes* This field is required.Use this area to describe the reconnect. Be as detailed as possible.

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Third Reconnect - List What Was Reconnected* This field is required.Select OTHER and enter description if RC is not listed.

Faucet

Existing Dishwasher - Air Gap

Existing Dishwasher - Drain

Garbage Disposal

P-Trap

Supply Lines

Other

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New or Used Faucet?* This field is required.

NEW FAUCETUSED FAUCET

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New or Used Garbage Disposal?* This field is required.

NEW DISPOSALUSED DISPOSAL

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Third Reconnect Notes* This field is required.Use this area to describe the reconnect. Be as detailed as possible.

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Fourth Reconnect - List What Was Reconnected* This field is required.Select OTHER and enter description if RC is not listed.

Faucet

Existing Dishwasher - Air Gap

Existing Dishwasher - Drain

Garbage Disposal

P-Trap

Supply Lines

Other

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New or Used Faucet?* This field is required.

NEW FAUCETUSED FAUCET

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New or Used Garbage Disposal?* This field is required.

NEW DISPOSALUSED DISPOSAL

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Fourth Reconnect Notes* This field is required.Use this area to describe the reconnect. Be as detailed as possible.

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Fifth Reconnect - List What Was Reconnected* This field is required.Select OTHER and enter description if RC is not listed.

Faucet

Existing Dishwasher - Air Gap

Existing Dishwasher - Drain

Garbage Disposal

P-Trap

Supply Lines

Other

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New or Used Faucet?* This field is required.

NEW FAUCETUSED FAUCET

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New or Used Garbage Disposal?* This field is required.

NEW DISPOSALUSED DISPOSAL

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Fifth Reconnect Notes* This field is required.Use this area to describe the reconnect. Be as detailed as possible.

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Did You Reconnect a Cooktop or Stove?* This field is required.

YESNO

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Was the Unit New or Used?* This field is required.

NEWUSED

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Was the Unit Gas or Electric?* This field is required.

GASELECTRIC

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Was the Gas Line New or Used?* This field is required.

NEWUSED

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Anything not mentioned on the previous pages is to be considered an additional item and charge. All additional items must have approval prior to beginning additional work. Are There Any Additional Items? (This includes Add-ons & change orders)* This field is required.NOTE - ANY ADDITIONAL WORK NEEDED FOR HDI JOBS MUST BE CALLED INTO THE OFFICE FOR APPROVAL FIRST.

YESNO

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How Many Angle Stops?* This field is required.

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How Many Water Filters / Reverse Osmosis RCs?* This field is required.

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How Many Ice-Maker RCs?* This field is required.

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How Many Cooktop RCs?* This field is required.

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How Many Garbage Disposal Re-Routes?* This field is required.

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How Many Changes Out of Piping (Galvanized / Cast Iron)?* This field is required.

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How Many New Dishwasher Installations?* This field is required.

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Misc 1 Details (Live Authorization Required)Include Description, Price, and Note of Verbal Authorization

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Misc 2 Details (Live Authorization Required)Include Description, Price, and Note of Verbal Authorization

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Misc 2 Price (Live Quotation Required)COST MUST BE APPROVED PRIOR TO SUBMISSION

ENTER NUMBERS ONLY

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Is There a PO# for The Additional Work?* This field is required.

YESNO

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Additional PO#* This field is required.

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Description of Additional Work* This field is required.

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Confirm the Date of Service* This field is required.

Date

Hour

Minutes

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Upload Multiple Job Pictures* This field is required.Upload AT LEAST 6 pictures of the site/completed work. All image and video files accepted.

Drag and drop files here

Select files to upload

Max. file size: 24.4MB

Maximum File Size: 24.4MB Per File

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Additional Comments for HDI - Warranty Information, Known Issues, Notes & Important Information

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How Many MDP Technicians Assigned to This Job?* This field is required.

1 (One)2 (Two)

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MDP Technician* This field is required.Select the name of the MDP representative below. If unlisted, select "Other."

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Installed By (Technician 2)* This field is required.Select the name of the MDP representative below. If unlisted, select "Other."

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I (the MDP technician) have checked all areas for gas & water leaks and there are none present at the time of this service.* This field is required.

YES - I HAVE INSPECTEDNO

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If the technician has not inspected, list the reasons why here:* This field is required.

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MDP Technician - Signature* This field is required.

Clear

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MDP Technician 2 - Signature* This field is required.

Clear

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Warranty Terms & Agreement* This field is required. I {customerName}, understand that there is a limited 1 year warranty on the plumbing work provided. This warranty is limited only to brand new equipment installed on this day. Any used equipment that has not been replaced is under no warranty. Please note: MDP cannot warranty stoppage clearing. Recurring stoppages may indicate other more complex problems in the drainage system. Any stoppages or plumbing issues that may originate in the future will be considered additional work and may require additional charges if the issues are not directly related to the work performed by MDP. The warranty is void if any outside work or modification takes place on the plumbing that has been installed by MDP by anyone other than an approved MDP Technician.

YES - I AGREENO

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Warranty Terms & Agreements - Customer Decline* This field is required.Please give a short description or reason why the customer declines to acknowledge the Warranty Terms & Agreement.

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By signing below, I understand and agree to the terms of the Warranty* This field is required.

Clear

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I acknowledge as the customer that I have personally checked all areas of plumbing worked on, including gas-line and electrical work, and I am satisfied with functionality of all items. I also confirm that to the best of my ability there are no gas leaks, water leaks or electrical problems present.* This field is required.

YES - I AgreeNO - I Do Not Agree

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Please briefly explain...* This field is required.Please explain why the customer has selected that they are not fully satisfied with the results of the work.

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By signing you agree that the information contained and submitted within this form is true and correct.

Clear

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Please verify that you are human* This field is required.

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Installer's Waiver and Release of Lien* This field is required.Upon receipt by the undersigned of a check from U.S. Remodelers, Inc. on behalf of the customer named above, and when the check has become properly endorsed and has been paid by the bank upon which it is drawn, this document shall become effective to waive, relinquish, and forever release any right of the undersigned or any laborer, mechanic, or materialman claiming through or under the undersigned, to a mechanic's lien, stop notice, or any right against a labor or material bond on the job performed for the customer and the location listed above. The undersigned represents that all laborers, mechanics, and materialmen furnishing services or materials on the job have been fully paid for their services or materials. The undersigned agrees to cause the prompt release of any liens which may be filed against the said premises by any laborer, mechanic, or materialman claiming the right to file such lien through or under the undersigned. The undersigned further agrees to hold harmless and indemnify The Home Depot and U.S. Remodelers, Inc., the named above, and the owner of title said premises, from and against all costs and expenses arising from or by reason of such lien of the release or discharge thereof. This waiver and release covers the payment to the undersigned for all labor, services, equipment, or material furnished on the job, except for disputed claims for extra work. Before any recipient of this document relies on it, the parties should verify evidence of the payment to the undersigned.

YES - I AGREENO

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By Signing, I Understand and Agree to the Installer's Waiver and Release of Lien* This field is required.

Clear

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JO Badge

JO Badge Expiration

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MDP Email

This hidden field is used to tell the form which email account it should send the results from.

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MDP From Name

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Angle Stop Cost

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Water Filter/Reverse Osmosis Cost

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Ice Maker Cost

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Cooktop Cost

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Re-Route Garbage Disposal Cost

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Change Pipe Cost

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New Dishwasher Cost

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Misc 1 Cost

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Misc 2 Cost

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Total Basic Reconnect CostCalculated Based Upon the Number of Standard Reconnects Submitted

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Total Additional Reconnect / Work Cost

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Calculated TotalBasic Reconnect Total+Additional Costs Total = Calculated Total

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Unique ID No.

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Form Version & Build

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Email Internal

example@example.com