PROPERTY LOSS & PRODUCT / EQUIPMENT FAILURE ANALYSES
Request for Analysis
Commercial & Residential Property Failures, Machinery, Appliances, Structural, Civil, Soils, Plumbing, Construction, Environmental, Electrical, Fire Origin & Cause, Industrial and Heavy Equipment
Name of Insured:
First Name
Last Name
Name of Claimant:
First Name
Last Name
Claim Number:
Date and Time of Loss:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Your Name:
Mr.
Mrs.
Prefix
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Your Company Name:
Your Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please address report and invoice to:
Email:
example@example.com
Shipping Address (if different from above):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Product
If not applicable please leave this section blank
Product (type):
Make:
Model & Model No.:
Location Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact:
Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
If Other was selected above, please elaborate:
Phase I (pick up evidence and documentation only)
Yes
No
N/A
Phase II (complete analysis requested)
Yes
No
N/A
Failed Product being shipped to Impact General?
Yes
No
Loss/Site Location
Location Type:
Commercial Site
Residential Site
Location Name:
Location Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Assignment:
Provide a detailed description of loss:
Analysis Requested:
Special Requests:
Time and/or Cost constraints:
Other:
Documents Submitted:
Photographs
Statement(s)
Owner's Manual
Repair/Service Records
Receipts
Other
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