Claim Number: {formtext: name=Claim Number; default=Copy and Paste Claim Number Here}
Customer Name: {formtext: name=Customer Name; default=Copy and Paste Customer Name Here}
Inspection Date: {time: MMMM Do YYYY}
Estimated Cost: {formtext: name=Estimated Cost; default=$}
Estimated Duration or Date for Completion: {time: MMMM Do YYYY}
Cause of Loss - Document what caused the damage. {formmenu: default=Plumbing; Sewer/Sump Pump Back Up (confirm limits with adjuster if not already provided); Appliance; Freeze; Unknown; Other; name=Source of Loss}
Any evidence of long-term leaking? {formmenu: Yes; default=No; name=Evidence of Long Term Leakage}Rot or mold present? {formmenu: Yes; default=No; name=Rot or mold present}Call adjuster to discuss coverage.
If freeze, does it appear the heat was maintained?{formmenu: Yes; default=No; Unsure; name=Was Heat Maintained}Unsure? Call adjuster to discuss coverage.
Cabinets damaged? {formmenu: Yes; default=No; Unsure; name=Cabinets Damaged?}How many LF? {formtext: name=Linear feet of Cabinets; default=\ LF}Cabinets should not be discarded until it has been established a repair is not possible.
Category and Class of Water
Cat: {formmenu: 1; default=2; 3; name=Category of Water} Class: {formmenu: default=1; 2; 3; 4; name=Class of Loss}
What supports this? {formtext: name=Source of Loss; default=} {formmenu: Category 1 - "Category 1 water originates from a sanitary water source and does not pose substantial risk from dermal, ingestion, or inhalation exposure. Examples of Category 1 water sources can include, but are not limited to: broken water supply lines\; tub or sink overflows with no contaminants\; appliance malfunctions involving water-supply lines\; melting ice or snow\; falling rainwater\; broken toilet tanks, and toilet bowls that do not contain contaminants or additives." - IICRC S500: 2021 Section B. Definitions - Page 15 Category of water may be obtained by objective means of testing water contamination level such as ATP testing. Please reference supporting documents and notes regarding the determination of the category level.\n; default=Category 2 - "Category 2 water contains significant contamination and has the potential to cause discomfort or sickness if contacted or consumed by humans. Category 2 water can contain potentially unsafe levels of microorganisms or nutrients for microorganisms, as well as other organic or inorganic matter (chemical or biological). Examples of Category 2 water can include, but are not limited to: discharge from dishwashers or washing machines\; overflows from washing machines\; overflows from toilet bowls on the room side of the trap with some urine but no feces\; seepage due to hydrostatic pressure\; broken aquariums, and punctured water beds." - IICRC S500: 2021 Section B. Definitions - Page 16 Category upgrade due to dwell time or odor - Made at the determination of the professional expertise of the franchise. Category may be determined by objective means of testing water contamination level such as ATP testing. Please reference supporting documents and notes regarding the determination of the category level.\n; Category 3 - "Category 3 water is grossly contaminated and can contain pathogenic, toxigenic, or other harmful agents and can cause significant adverse reactions to humans if contacted or consumed. Examples of Category 3 water can include, but are not limited to: sewage\; wasteline backflows that originate from beyond any trap regardless of visible content or color\; all forms of flooding from seawater\; rising water from rivers or streams\; and other contaminated water entering or affecting the indoor environment, such as wind-driven rain from hurricanes, tropical storms, or other weather-related events. Category 3 water can carry trace levels of regulated or hazardous materials (e.g., pesticides or toxic organic substances)." - IICRC S500: 2021 Section B. Definitions - Page 16 Category upgrade due to dwell time, presence of microbial growth, or odor - Made at the determination of the professional expertise of the franchise. Objective means of testing water contamination level such as ATP testing. Please reference supporting documents and notes regarding the determination of the category level.\n; name=Category} {formmenu: default=Class 1 - "(least amount of water absorption and evaporation load): Water intrusion where wet, porous materials (e.g., carpet, gypsum board, fiber-fill insulation, concrete masonry unit (CMU), textiles) represent less than ~5% of the combined floor, wall and ceiling surface area in the space\; and where materials described as low evaporation materials or assemblies have absorbed minimal moisture (see definitions for Class 4 and low evaporation assemblies)." - IICRC S500: 2021 Section B. Definitions - Page 16\n; Class 2 - "(significant amount of water absorption and evaporation load): water intrusion where wet, porous materials (e.g., carpet, gypsum board, fiber-fill insulation, concrete masonry unit (CMU), textiles) represent ~5% to ~40% of the combined floor, wall and ceiling surface area in the space\; and where materials described as low evaporation materials or assemblies have absorbed minimal moisture (see definitions for Class 4 and low evaporation assemblies)." - IICRC S500: 2021 Section B. Definitions - Page 16\n; Class 3 - "(greatest amount of water absorption and evaporation load): water intrusion where wet, porous materials (e.g., carpet, gypsum board, fiber-fill insulation, concrete masonry unit (CMU), textiles) represent more than ~40% of the combined floor, wall and ceiling surface area in the space\; and where materials described as low evaporation materials or assemblies have absorbed minimal moisture (see definitions for Class 4 and low evaporation assemblies)." - IICRC S500: 2021 Section B. Definitions - Pages 16-17Class 3 - "(greatest amount of water absorption and evaporation load): water intrusion where wet, porous materials (e.g., carpet, gypsum board, fiber-fill insulation, concrete masonry unit (CMU), textiles) represent more than ~40% of the combined floor, wall and ceiling surface area in the space\; and where materials described as low evaporation materials or assemblies have absorbed minimal moisture (see definitions for Class 4 and low evaporation assemblies)." - IICRC S500: 2021 Section B. Definitions - Pages 16-17\n; Class 4 - "(deeply held or bound water): water intrusion that involves a significant amount of water absorption into low evaporation materials (e.g., plaster, wood, concrete, masonry) or low evaporation assemblies (e.g., multilayer wallboard, multilayer subfloors, gym floors, or other complex, built-up assemblies). Drying may require special methods, longer drying times, or substantial water vapor pressure differentials." - IICRC S500: 2021 Section B. Definitions - Page 17\n; name=Class}Support must be documented in the file and adhere to IICRC standards.
Notes & Reminders- copy into XA when needed
Asbestos or lead present? {formmenu: Yes; default=No; Unsure; NA; name=Asbestos/Lead}Plan of action {formtext: name=Plan of Action}
If more than 100 sf of flooring is affected, make sure an ITEL sample is taken and submitted. {formtext: name=ITEL Sample}
Water still leaking? {formmenu: Yes - Adjuster has been contacted; default=No; name=Still Leaking?}Contact the adjuster
Mobile home? {formmenu: Yes; default=No; name=Mobile Home}Confirm limits with the adjuster if extensive damage.
Multiple chambers should be supported by established standards. {formtext: name=Multiple Chambers; default=Chambers separated by doors or containment and photographed for support.}
Need a pack out? {formmenu: Yes; default=No; Unsure; name=Packout}If yes, call adjuster to discuss and request a separate Service.
Don’t forget to call the adjuster by day 3 to discuss mitigation drying plan and any concerns.
Exceptions needed? Call corporate to discuss and not the adjuster