Photo Evaluation Form
Adjuster Name:
First Name
Last Name
Adjuster E-mail
*
example@example.com
Primary Phone Number
*
-
Area Code
Phone Number
Insurance Company
*
Claim #
*
Date of Loss
-
Month
-
Day
Year
Date
Insured Address
*
Street Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Window Brand
If multiple brands note here
Manufacturer Date
Year
Examples of Brand / Series Identifiers
Detailed Photo
Detailed Photo
Detailed Photo
Detailed Photo
Detailed Photo
Detailed Photo
Detailed Photo
Front Elevation
*
Affected number of windows on specific elevation
Overview Photo
Window attribute
Right Elevation
*
Affected number of windows on specific elevation
Overview Photo
Window attribute
Rear Elevation
*
Affected number of windows on specific elevation
Overview Photo
Window attribute
Left Elevation
*
Affected number of windows on specific elevation
Overview Photo
Window attribute
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Description of problem
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Should be Empty: