JCS Restore Fire Damage Form

Fire Damage 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
Date of Loss

Month Day Year
Time of Loss

: Hour Minutes AM/PM Option
Insurance Provider
Have you contacted your insurance?

Yes No
Has a plumber been out there?

Yes No
Affected Areas

Outside Living Room Dining Room Kitchen Den / Study Hall Ways Bathrooms Bedrooms Garage Doors Windows Appliances Fixtures Electrical Flooriing Ceiiling Walls
Materials Damaged

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

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