JCS Restore Odor Form

Mold Removal Checklist
Customer Name
Phone Number*

Area CodePhone Number
E-mail address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Loss

MonthDayYear
Time of Loss

:HourMinutesAM/PM Option
Insurance Provider
Have you contacted your insurance?

YesNo
Has a plumber been out there?

YesNo
Affected Areas

BedroomBathroomLiving RoomKitchenOther
Causes of Loss

WaterFireMoldOther
Material Damaged

CarpetTileWoodLaminateFurnitureAppliancesOther
How did you hear about us?

PlumberReferralInternet SearchInsurance ProviderOther
Additional Information
Should be Empty: