Test Request Form (REQUIRED on insurance claims …

1 ` 6745 Philips Ind. Blvd. Jacksonville, FL 32256 800-890-ITEL (4835)customers ervic Request form insurance Carrier ( required on insurance claims ) insurance Carrier: claim Office: Staff Adjuster: Phone: E-Mail:Fax: EXPRESS SAME-DAY SERVICEA vailable 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. Cat Code: Today s Date:Loss Date:Bill To: . Third Party Independent Adjuster er Independent Adjuster Adjusting Firm: Adjuster: Phone: E-mail: Fax: Third Party (Store, mitigation vendor, 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*: Vendor Job Number: Sample Color: Damaged Area: Area of Loss (Size in Square Feet): Policy Type: Residential / Personal Commercial claim Type: Cat Water Fire Wind Hail Other Comments:Flooring Siding and Roofing Sample Requirements Carpet Vinyl Sheet/Tile Siding If known: Year Installed: or Year the cleanest, least damaged sample one form for each flooring, roofing, or siding sample.

2 Note pad on the same form as the corresponding flooring : 10" x 10"; pad 6" x 6". sheet: 4" x 4" or larger. , wood, and vinyl plank: full width including lock and 10" of length. Ceramic, vinyl, and stone tile: 6" x 6"; full tile if : 1 foot section that includes the full height from nail hem to bottom butt edge include the manufacturer number or codes and weep hole if available. Roofing: Send full shingle or tile. Roll or fold shingle if it is too large to fit in a shipping 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 Ceramic/Stone Floor or Wall Tile Color variation among tiles: Significant None Some " x " Flooring Pad / Underlayment Pad analysis included in the flooring test of Shingles Damaged*: * required for roofing testsOther Analysis Asbestos Check to add asbestos analysis.

3 Three samples taken from random areas of the material are required for vinyl Material (specify type): Don t know where to turn? ITEL can perform a custom analysis for you. Contact Customer Service for details. QUESTIONS? Contact ITEL Customer Service at 800-890-4835 or Full Tile Size:square feetExt.:Ext.:Ext.: form Completed By: insurance Carrier Third Party Independent Adjuster insurance Carrier Other (list).