Damage Report

Date:

Customer name:

Address:

Home Phone:

Technician on duty:

Item(s) description:

Replacement value of item(s):

Please describe the incident that caused the damage:

Can item be repaired?

Was customer notified?                If yes, by whom?             If yes, date and time:

Please describe follow-up procedure (I.e., item repaired or replaced):

Cost:

Was insurance company notified?  

Date of insurance company notification: