JCS Restore Fire Damage Form

Address

Date of Loss

- Month - Day Year
Time of Loss

: Hour Minutes
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: