Call Report Form
Job Information
Date:______________________Time Called In:______________Date of Loss:________________Job No:______________
Contact:______________________________________________Relationship:____________________________________
Job Address:__________________________________________Site Phone:_____________________________________
City::_________________________________________________Work Phone Mr.:_________________________________
State: _____________________Zip: _______________________Work Phone Mrs:________________________________
Other:______________________________________________________________________________________________
Insured Information
Insured:____________________________________________________________________________________________
Bill Address:___________________________________________Home Phone:___________________________________
City:_________________________________________________Work Phone Mr:_________________________________
State:______________________Zip:________________________Work Phone Mrs:________________________________
Motel________________________________________________Phone_____________________Ext:_________________
Other:______________________________________________________________________________________________
Insurance Information
Ins. Company:_________________________________________Policy :________________________________________
Ins. Agency:___________________________________________Contact:________________________________________
Agency Address:_______________________________________Phone:_________________________________________
City:_________________________________________________State:______________________Zip:_________________
Adjusting Co:__________________________________________Adjuster:_______________________________________
Adjuster Address:______________________________________Phone:_________________________________________
City:_________________________________________________State:______________________Zip:_________________
Directions to Job
Map Page: Coordinates:
1-17
Telephone Questions:
Is there any standing water? Yes No Is there electric power available? Yes No
Has the source of water stopped? Yes No Is the heat system still working? Yes No
Is there any large furniture? Yes No Have you called your insurance agent? Yes No
Is there anyone with allergies? Yes No Have you called a repair person? Yes No
Have called health inspector? Yes No Are you still living in structure? Yes No
Notes:
Cause of loss:
Areas Affected: Which areas and the type of flooring affected: C-Carpet, V-Vinyl, T-Tile, H-Hardwood, O-Other
Hall: Liv Room: Rec Room: Dining: Kitchen: Bath:
Hall: Study: Den: Master Bed: Bedroom: Bedroom:
Other areas affected:
General and Payment Information
Age of the structure: Style:
Steps already taken:
Special concerns of customer:
Has anyone already inspected the situation: Yes No Name: Title:
How will you handle the emergency fee:
Marketing Information
Where did you get our phone number?
How did you first learn about our company?
Referring Company: Referring Individual:
Instructions to Customer:
Emergency Service Response:
Technicians Notified Name: Time: By:
Technicians Arriving Name: Time: By:
