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CLIENT QUESTIONNAIRE
Client Questionnaire
Date of Backup
MM slash DD slash YYYY
Name
First
Last
Phone Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Provide names and ages of all people living or working (full time) in the flooded property.
Date(s) of the sewer backup.
Have you ever had sewer issues before? If so, when?
Yes
No
When?
MM slash DD slash YYYY
Do you own or rent?
Own
Rent
If you own the property, how long have you owned the property and what is the value of the property? (Please provide a copy of the deed to your home upon the return of this paperwork.)
Have you been displaced? (i.e. living with family, hotel, car etc.)
Yes
No
Have you filed a Notice of Tort Claim? If yes, when?
Yes
No
Date
MM slash DD slash YYYY
Has the property been cleaned?
Yes
No
Estimated damages?
Has the property been restored to pre-backup condition?
Yes
No
Have you had a plumber check your lateral line BEFORE and/or AFTER the sewer flood?
Yes
No
Does your property have a backflow preventer?
Yes
No
Did you call the City to report the sewer backup?
Yes
No
Do you have photos, videos and/or photos of the subject backup? If so, please provide them upon submission of the Questionnaire.
Yes
No
Please describe in narrative form what happened.
Please complete the above form and upload any photos, videos, estimates, receipts, property deed and/or invoices.
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