Status
Please Select
need reviewed
follow-up
need scheduled
scheduled
rescheduled
processing report
completed
cancelled
For Administrative Use Only
Job ID
For Administrative Use Only
Scheduling ( For Administrative Use Only )
Site Visit Appointment
End of In-Form Scheduling Section
In-Form Follow-Up
Select Follow-Up Contact
Please Select
No Follow-Up
Requestor
Business Contact
Primary Site Contact
'No Follow-Up' will set contacts to empty
Follow-Up Contact Email
For Administrative Use Only
The Send-To Follow-Up Name
The greeting name in the follow-up email.
The Send-From EPI Contact EMail
For Administrative Use Only
Follow-Up Request
For Administrative Use Only
End of In-Form Follow-Up Section
EPI Job Request Form
Requestor
Business
Individual
Other
Job Submission Status
New Job Request
Follow-Up on existing Job Request
Other
Business Type
Insurance Company
Restoration Company
Roofer
Attorney
Public Adjuster
Residential
Other
Structure Type
Commercial Building
Industrial Building
House
Other
Type of Job Request
Fire
Roof
Wind and/or Hail
Vehicle Impact
Industrial Equipment
Water Intrusion
Mold
Snow Loads
Expert Witness
Trip and Fall
Moisture Issue
Tree Impact
Foundation
Other
Contact Information
Requestor or Client Full Name
*
First Name
Last Name
Requestor Phone Number
Please enter a valid phone number
Format: (000) 000-0000.
Requestor Email
*
example@example.com
business contact section
Business Name
Business Contact Name
First Name
Last Name
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Email
example@example.com
end of business contact information
Claim or PO Number
Provided by Insurance Company
Billing Email
The email address to send the invoice
Site Information
Site Inspection Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Site Contacts
Please Select
0
1
2
3
Please select number of contacts that will be at the site during the investigation
primary site contact
Primary Site Contact
Same as requestor
Same as business contact
Other (Please specify below)
Primary Site Contact Name
First Name
Last Name
Primary Site Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Site Contact Email
example@example.com
second site contact
Second Site Contact
Same as requestor
Same as business contact
Other (Please specify below)
Second Site Contact Name
First Name
Last Name
Second Site Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Second Site Contact Email
example@example.com
third site contact
Third Site Contact Name
First Name
Last Name
Third Site Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Third Site Contact Email
example@example.com
site or incident details
Site or Incident Report Details
Report Requirements
Opinion Only
Full Report
Drawings
Other
Date of Incident or Loss ( if known )
-
Month
-
Day
Year
Date
Site or Incident Description or Comments
Please Submit Related Documents or Images
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Operational Section
blank contact
For Administrative Use Only (to set follow up contact to fields to empty)
Should be Empty: