• Your Email:
*
example@example.com
• Your first name and shortened company name:
*
• Is this a FIELD-based estimate or a REMOTE/DESK-based estimate? In other words, is an on-site field inspection required to complete this estimate?
On-Site Inspection: A field visit to the property will be needed
Remote Desk Estimate: This is a 'desk-based' remote assignment and I will provide the information to complete the estimate
• How many total claims are at this property?
*
Only 1
2 Total Claims
3 Total Claims
• Type of Estimate(s) Requested (Check all that apply):
*
Water Mitigation
Cat. III/Sewage Water Loss
Tarp Application
Fire/Smoke/Soot Cleaning &/or Rebuild
Rebuild/Reconstruction
Mold Remediation
Microbial Testing/Assesssment Assignment
Appraisal Assignment
• Is this a particularly large job that we will need more than two hours on-site time?
Yes
• Who should we contact to coordinate the appointment?
Me (the person filling out this form)
Please coordinate directly with the homeowner
Please coordinate with the tenant/renter of the property
• Would you like to be present during estimate field inspection?
Yes
No
• Name of Homeowner / Property Owner / Your Clients / Insured Name:
*
• This is the official name that will go on the coverpage of the estimate. This is usually the homeowner, insured, business, or policyholder name. This is NOT the name of you or your company.
• Street Address of Property:
*
• City, State, Zip:
*
• Building/Unit # & Community Name:
• Mobile Phone # of Your Client or Contact:
*
Please also list any tenant or other contact info that we may need
• Date of Loss:
-
Month
-
Day
Year
Date Picker Icon
• Insurance Carrier Name:
• Claim #:
• Policy #:
• Type of Loss:
• If 'Water Loss', please state what *type* of water loss, such as appliance, plumbing supply line, drain line, HVAC, etc.
• Deductible To Apply $:
If you'd like us to apply a deductible to your estimate, please enter it here.
• Estimated Estimate Amount $:
• If you have an estimated dollar-figure of what you think this estimate will arrive at, please list it here. This question usually pertains to contractors as this helps to give us an idea of how large the anticipated scope of work will be.
• Components to be included in estimate:
*
Roof - Full replacement
Kitchen - Cabinetry / countertop replacement (or partial)
Bathroom(s) - One or more bathroom(s) to be fully replaced (Shower/vanity/tile walls/etc.)
Tile Floor(s) - Full tile flooring replacement throughout all continuous areas
Not Applicable / Not Sure
• Bills, Invoices, Receipts, &/or Proposals:
• Please tell us, if any, bills, invoices, receipts, &/or proposals to include in the estimate. Remember to include the total amounts and what company they come from.
• Scope of Work Notes & Other Assignment Notes:
• Give us a basic idea what this estimate will consist of; list all areas, continuous areas, matching areas, etc. that you'd like us to include in the estimate. For example, if you'd like the roof to be included in the estimate, please mention that. The more specific you are, the faster & better your estimate with turn out!
Claim #2
Type of Loss:
Claim #:
Policy # (If Different):
Date of Loss:
-
Month
-
Day
Year
Date Picker Icon
Insurance Company:
Deductible To Apply $:
Estimate Notes / Scope of Work:
Claim #3
Type of Loss:
Claim #:
Policy #:
Date of Loss:
-
Month
-
Day
Year
Date Picker Icon
Insurance Company:
Deductible $:
Estimate Notes / Scope of Work:
Click below to upload files pertaining to this assignment:
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Water Mitigator / Mold Remediator Section
Is this a PROPOSAL or INVOICE?
Proposal/Bid (Job has not been completed yet)
Invoice (Job has been completed)
Pricing style:
Xactimate-ONLY pricing - Only use Xactimate prices for items
I would like to use 'Custom Unit Pricing'. (Please enter custom pricing in chart below)
What do you approximate this estimate should be around, dollar-wise? If you don't know, just write "Whatever":
*
This is extremely helpful and will give us an idea of where you are anticipating the total of your estimate to be at/around.
If this was an emergency service call, did the initial call take place DURING or AFTER business hours?
During Business Hours
After Business Hours
Apply debris removal fee to this invoice or proposal?
Yes
No
Technician Labor Hours Chart:
# of Technicians
# of Hours Per Tech
# of AFTER Hours Per Tech
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Other labor-related notes:
Machines, Equipment & Supplies Needed:
How many
How many days ea
# of Filters
Custom Pricing Per Ea
Dehumidifiers
Air Movers
InjectiDry
Air Scrubbers
Hydroxyl Machine
Other Materials:
Qty/Amount
Custom Pricing Per Ea. $
Contents Packout - How many boxes?
ULV Fogging - per cubic Ft.
Anti-microbial spray - per sq. ft.
Encapsulation - per sq. ft.
Containment Barrier(s) - per sq. ft.
How many zippers used
Sq. ft. of floor protection
Sq. ft. of contents cover/protect
# of Garbage bags
# of PPE's (Personal Protective Equipment)
HVAC Cleaning & Decontamination:
Air handler only
Duct system only
Air handler & duct system
None/Does not apply
# of Ducts Cleaned/Treated:
Apply infra-red camera charge/moisture detection/evaluation fee?
Yes
No
Mold Testing:
Amount $
Pre-Test $
Post-Test $
Tarp Application:
Amount
Tarp (Poly Tarp) Size (IE: 20x30)
Shrink-Wrap Tarp Total sq. ft:
# of Sandbags Used
# of wood strip battens
How many hours did the tarp application take?
File Upload Option A) Use this one to upload 10-20 files that aren't too large:
Browse Files
Click button above to upload a small amount of files. They cannot be too large as well.
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• Large File(s) Upload Web Portal (Click Here)
Click the link above if you have a large amount of photos or other documents to upload (too many to attach to a regular email)
Submit
Should be Empty: