Fillable Itel Test Request Form V2

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Itel Test Request Form V2

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  • 32 check-boxes
  • 35 other fields

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File type: PDF

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˧`
6676 Corporate Center Pkwy #107
Jacksonville, FL 32216
800-890-ITEL (4835)
customerservice@itelinc.com
www.itelinc.com
Test Request Form
Cat Code:
EXPRESS
SAME-DAY SERVICE
Available on carpet, pad, vinyl, wood,
laminate, siding, and asphalt roofing
tests for an additional charge.
If not checked, your report will be
sent the next business day after the
sample is received at ITEL.
Insurance Carrier (All fields REQUIRED on insurance claims.)
Insurance Carrier:
________________________________________
Claim Office:
________________________________________
Staff Adjuster:
________________________________________
Phone:
________________________________________
E-Mail:
________________________________________
Fax:
________________________________________
Today’s Date: ________________
Loss Date: __________________
Bill To
Insurance Co. Third Party Independent Adjuster
(Reports will be sent to all listed parties)
Form Completed By
:
Insurance Co. Third Party Independent Adjuster
Other (
List
): ____________________________________________
Independent Adjuster
Adjusting Firm:
________________________________________
Adjuster:
________________________________________
Phone:
________________________________________
E-mail:
________________________________________
Fax:
________________________________________
Third Party (Vendor, store, contractor, etc.)
Company:
_____________________________________________
Contact:
_____________________________________________
Phone:
_____________________________________________
E-mail:
_____________________________________________
Fax:
_____________________________________________
Loss Information (* INDICATES A REQUIRED FIELD. If NOT an insurance claim, list the customer’s information.)
Insurance Claim Number*:
____________________________________
Insured Name*:
____________________________________
City, State, and Zip Code of
Loss Location*:
(Include Province and Postal
Code for Canada)
Vendor Job Number: ______________________________________
Sample Color: ____________________________________________
Name of Damaged Area: ___________________________________
Area of Loss
(Size)
: _____________ Sq. Ft. Squares
Policy Type:
Residential / Personal Commercial
Claim Type: Cat Water Fire
Wind Hail Other
Comments (
Brand, description of sample, etc.):
Flooring
Siding and Roofing
Sample Requirements
Carpet
Vinyl Sheet/Tile
Siding
If known:
Year Installed: _______
or
Year Built: _______
1. Send the cleanest, least damaged
sample possible.
2. Include one form for each flooring,
roofing, or siding sample. Note pad on
the same form as the corresponding
flooring sample.
3. Carpet: 10" x 10"; pad 6" x 6".
4. Sheet / tile vinyl: 2" x 2" or larger.
5. Laminate, wood, and vinyl plank: full
width including lock and 10" of length.
6. Tile / stone: 6" x 6", or full tile if smaller.
7. Siding: 1 foot section that includes the
full height from nail hem to bottom butt
edge. Also include the manufacturer
number or codes and weep hole if
available.
8. Roofing: Send full shingle or tile. Roll or
fold shingle if it is too large to fit in a
shipping bag.
9. Other Material: Contact ITEL for details.
Laminate
Wood
Add Match Report
For potential wood or laminate
repairs; send full width sample
that includes lock. Add’l charge.
Roofing
Number of Shingles Damaged*:
*Required for Discontinued Shingle Location
upgrade; call Customer Experience for details.
Ceramic/Stone Floor or Wall Tile
Color variation among tiles:
None Some Significant
Full Tile Size: _______ " x _______ "
Flooring Pad / Underlayment
Pad analysis included in the flooring test price.
Other Analysis
Asbestos
Check to add asbestos analysis.
Three
samples taken from random areas of the
material are required for vinyl tile
.
Other Material
(specify type)
:
_________________________________
Don’t know where to turn? ITEL can
perform a custom analysis for you.
Contact Customer Experience for details.
QUESTIONS?
Please contact our Customer Experience team at 800-890-ITEL (4835) or customerservice@itelinc.com.
Rev.5/19
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Itel Test Request Form V2

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Completed 30 July 2020

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