JCS Restore Reconstruction Form

Reconstruction Checklist
Customer Name
Phone Number *

Area Code Phone Number
E-mail address
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Insurance Provider
Have you contacted your insurance?

Yes No
Affected Areas

Bedrooms Bathrooms Living Room Dining Room Kitchen
Causes of Reconstruction

Water Fire Mold
Material Damaged

Carpet Tile Wood Laminate Furniture Appliances
How did you hear about us?

Plumber Referral Internet Search Insurance Provider
Additional Information
Should be Empty: