Your form may be slightlty different.
help with these instructions, call ITEL’s Customer Service Team: 800-890-ITEL (4835) Monday - Friday, 8:00
AM to 9:00 PM Eastern Time. You can also e-mail our team: customerservice@itelinc.com.
page 2 of 2
Sample collection complete!
The ITEL report will be returned to your adjuster the next business day after we receive
the sample.
For questions on the results or your claim, please contact your insurance adjuster. If you need
Send the sample
If the sample is wet, enclose the form in a ziplock-style bag before shipping.
Place the form and sample in a sturdy shipping envelope or box, attach the label, and
seal the package. Express Pak envelopes are available free at UPS Stores®. You can
drop the sample off
at a UPS drop box or take it to a UPS
Store. Drop box and store
locations are available at www.ups.com/dropoff. If using your own shiping, send the
sample to:
ITEL Laboratories
6676 Corporate Center Pkwy
Suite 107
Jacksonville FL 32276
The top part of the peel-and-
s
tick label should be placed on
the envelope.
If you have downloaded the
label, you will need to tape the
label to your package using
clear packing tape.
The bottom part is your
return receipt. It includes
the UPS
tracking number
and should be kept for
your records.
Downloaded labels will
not have the return
receipt; please keep a
copy of your tracking
number for reference.
Step 3: Ship the sample using the pre-addressed UPS® label
Need a shipping label? Download a shipping label at itelinc.com. There is no need to pre-pay the
shipping when using the ITEL shipping label.
Billing
Check the box to indicate if you
are paying for the analysis by
check or credit card.
For credit card payment, do not
include your credit ca
rd number.
An ITEL representative will call for
your payment information.
Step 2: Fill out the “Homeowner’s Test Request Form”
Complete the Test Request Form.
All information is required
except where noted.
1. List your information.
2. List insurance company
information
3. Check appropriate box
for enclosed sample.
6745 Philips Industrial Blvd.
Jacksonville, FL 32256
Phone: 800-890-ITEL (4835)
Fax: 904-363-2379
www.itelinc.com
HOMEOWNER'S FLOORIN
TEST REQUEST FORM
BEFORE SENDING MAKE SURE YOU...
1. Enclose this form in a sealed plastic bag if the sample is wet.
2. Send the cleanest, lea
st damaged sample possible.
3. Collect the flooring b
ased on the instructions in the kit.
4. Completely fill out yo
ur contact and billing information.
Today's Date: _________________________________
Date Damage Occurred: ______________________
___
Homeowner Information (All fields required)
Homeowner's Name:
___________________________________________________________________
Phone #:
___________________________________________________________________
Fax # or E-mail Address:
___________________________________________________________________
City, State, and Zip Code
(Damaged house):
___________________________________________________________________
Insurance Company (Complete if your flooring is part of an insurance claim)
Insurance Company:
___________________________________________________________________
Claim Number:
___________________________________________________________________
Adjuster Name:
___________________________________________________________________
Adjuster Phone Number:
___________________________________________________________________
Adjuster Fax # OR E-mail:
___________________________________________________________________
SSaammppllee EEnncclloosseedd ((IInncclluuddee oonnee ffoorrmm ppeerr fflloooorriinngg ssaammppllee))::
Flooring
Description: ___________________________________________
Room(s): ______________________________________________
Pad or underlayment (free test if sent with flooring sample)
Description: ____________________________________________
Room(s): ________
______________________________________
SAMPLE REQUIREMENTS:
Flooring:
1.
Carpets should be 10" x 10"; pads should be 6"
x 6". Smaller samples may affect accuracy.
2. Sheet and tile vinyl should be at least 2" x 2".
3. Send the full width and 10" of length for
laminate, wood, and vinyl plank. If the full width
is not available, note
it on the form.
TTeesstt aanndd SShhiippppiinngg FFeeeess**::
Test Fee:
$##.##
Pre-Paid Shipping: $ #.##
$##.##
For security, do not include your credit card
number on this form. An ITEL account
representative will contact you for credit card
payments.
Checks are payable to ITEL, Inc.
*Fees valid through 12/31/08. Contact ITEL
Customer Service for current fees, or visit our
website: www.itelinc.com
BBiilllliinngg ((cchheecckk oonnee))::
Call homeowner for credit card
Check enclosed
QQUUEESSTTIIOONNSS?? Please contact our Customer Service team at 800-890-ITEL (4835) or custserv@itelinc.com.
Rev. 08/08
Homeowner’s Guide: Homeowner’s Guide: Submi�ing Samples Submi�ing Samples page 2page 2
