FPT Environmental, LLC
info@fptenvironmental.com
| T: (954) 673-5501 |
www.fptenvironmental.com
Project Request Form
Thank you for considering FPT Environmental
Have you spoken to anyone on our team?
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No One
Moe / Alvaro Zuluaga
Erika Collantes
Louis Adams
Christopher Schieb
Gwynne Beatty
Ilan Weizman
Rosix Hernandez
Karen Figueroa
Maria Monascal
Who is filling out the form?
*
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Homeowner
Tenant
Third Party / Contractor
Sales Representative
Sales Representative's Name
Customer Information
Requester's Name
First Name
Last Name
Requester's Phone
Please enter a valid phone number.
Requester's Email
example@example.com
Requester's Company
Company name of person requesting project
Requester's Project Function
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Attorney
Adjuster
Remediator
Property Manager
Other
Requester's Project Function if "Other"
If Requester's Project Function is "Other", please specify
Client Name
*
First Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Preferred Method of Electronic Communication
Email
Text
Phone Call
Contact Name
First Name
Last Name
Contact Phone Number
Contact E-mail
example@example.com
Relationship to Client
Loss Information
Project Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Address
Billing Street Address
Billing Street Address Line 2
Billing City
Billing State / Province
Billing Postal / Zip Code
Property Type
Residential
Commercial
Year Built
Year the building was constructed.
Date of Loss
-
Month
-
Day
Year
When did the loss occur?
Cause of Loss
*
Please Select
Asbestos
Biohazard
Contents
Earthquake
Fire
Flood
Hail
Mold
Other
Plumbing
Sewage
TMP
Water Damage
Wind
Select one of the following options
Service to be Provided
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Please Select
Inspection / Assessment
Mold Remediation
Water Mitigation
Consultation
Moisture Mapping
Matterport
Project Management
Odor Removal
Other
Unsure
Select one of the following options
Service if "Other"
Rooms Affected
Please Select
0-3 rooms
4-6 rooms
7-10 rooms
10+ rooms
Number of rooms affected by the cause of loss.
Loss Description
Provide a brief description of the situation, requests, comments or other relevant information such as gate code, pets present, urgency, etc.
Please feel free to attach photos or videos to show us the problem; also upload any documentation, insurance policies if needed:
Browse Files
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Upload any photo, video, documentation or picture taken in front of the structure
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Payment Information
How will this project get funded?
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Self Pay
Insurance
Who is responsible for paying?
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Owner
Property Manager
Company
Insurance Company
Name of insurance company
Policy #
Claim #
Contact Type
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Adjuster
Business contact
Independent Adjuster
Insurance Agent
Plumber
Property Manager
Public Adjuster
Roofer
Sub-contractor
Third Party Aministrator
Contact Name
First Name
Last Name
Contact Phone Number
Please enter a valid phone number.
Contact Email
example@example.com
Additional comments: Please let us know if there's anything else you'd like to share with us.
Additional notes or requests: gate code, pets present, urgency, etc.
Referral Information
How did you hear about us?
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Adjuster
Assessor
Attorney
Contractor
Course
Doctor
Friend / Family
Insurance Company
Internet / Google
Other
Property Manager
Real Estate Agent
Remediator
Respirair Lab
TPA
Website
Type of Referrer
Please Select
Attorney
Contractor
Doctor
Friend / Family
Property Manager
Real Estate Agent
Remediator
Name of Referrer
Source if "Other"
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