Service Request Form

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SERVICE
REQUEST FORM

Items indicated in red and by an asterisk (*) are required.

* Date of Service Request:
* Date of Loss:
* Insured's Name:
* Street Address:
* City:
* State:
* Zip Code:
* Home Phone Number:
Work Phone Number:
Cell Phone Number:

LOSS LOCATION, IF DIFFERENT
Street address:
City:
State:
Zip Code:

* Item(s) to be Inspected or Picked Up:

	Boiler	Furnace	Chimney
	Freeze Up	Lightning	Electrical
	#Hot Water Heater	#Well Pump	#A/C Compressor
Appliance: Other:

#These items must be detached from any piping or disconnected from system before pick-up.

*Description of Loss: Please describe as much supporting detail as possible. This will allow us to handle the claim better and faster. Supporting Documentation may be e-mailed to: service@iseengineering.com or faxed to: (508) 226-8880.
Check here if loss has the potential for ending up in subrogation and you would prefer to have one of ISE's senior personnel assigned to the loss. Our work on these losses will be billed at an hourly rate.

* Insurance/Adjusting Company:
* Contact at Insurance Company/Carrier:
Address:
City:
State:
Zip Code:
* Phone Number:
Fax Number:
Email Address:
Insurance Carrier:
* Policy Number:
* Claim Number:

* Send Report To:
* Send Invoice To:
Email Address to Receive a Copy of this Submission:
* Send final report by:	Email US Mail

Thank you for your business.
We will be contacting you shortly to confirm receipt of your claim.

If you do not hear from our offices within 24 hours, please contact us
at (508) 226-8800 to confirm that we have received your claim.