JCS Restore Reconstruction Form

Reconstruction Checklist
Customer Name
Phone Number*

Area CodePhone Number
E-mail address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Provider
Have you contacted your insurance?

YesNo
Affected Areas

BedroomsBathroomsLiving RoomDining RoomKitchenOther
Causes of Reconstruction

WaterFireMoldOther
Material Damaged

CarpetTileWoodLaminateFurnitureAppliancesOther
How did you hear about us?

PlumberReferralInternet SearchInsurance ProviderOther
Additional Information
Should be Empty: