Test Request Form (REQUIRED on insurance claims) Cat Code ...

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. Three samples taken from random areas of the material are required for vinyl Material (specify type): Don t know where to turn?

3 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).