FirstField

Job ID / Work Order #

Insurance Claim?

Yes

No

Date of Loss

Cause of Loss

Loss Category

Affected Class

Property Type

Loss Address

Owner/Customer Full Name

Owner/Customer Phone

Owner/Customer Email

Occupant/Agent Name (if different)

Role of Signer

Ambient Temp °F

RH %

GPP

Moisture Readings

Punctuality

Communication & Transparency

Professionalism & Courtesy

Care for Property & Cleanliness

Quality of Work Performed

Overall Satisfaction

Net Promoter Score (0-10)

Comments / Concerns

Permission to share testimonial/comments?

Contract/Estimate Total

Deductible

Payments Received

Balance Due

Direction to pay insurer proceeds to First Solution Service

I acknowledge that services were completed to my reasonable satisfaction, work areas were left in clean condition, and equipment listed has been removed unless noted above.

IICRC Note: Services were performed in accordance with generally accepted industry guidelines (incl. IICRC S500) where applicable. This is not a warranty or guarantee of conditions outside our scope.

Owner/Authorized Agent

Full Name

Signature

Company Representative

Full Name

Signature

I consent to the use of electronic records and signatures.

I consent to First Solution Service storing, processing, and sharing this information with my insurer/adjuster as needed for the claim.

FIRST SOLUTION SERVICE

Certificate of Satisfaction

Equipment Log

Moisture Readings

Owner/Authorized Agent

Company Representative