REQUEST FOR LIGHTNING/SURGE
VERIFICATION INSPECTION
Please be advised that this service for Air Conditioning Systems is
only available in the the following areas at this time:

The Greater Tampa Bay Area, Tampa, FL
The Greater Metro Atlanta Area, Atlanta, GA

Investigations of severe lightning damage to major equipment such as
TV & Radio Transmitters, Electrical Service Systems and Sub-Stations,
Transformers, Cat-Scan/MRI equipment, etc. is available nationwide.
Should you have a question about the above services
please e-mail us at jjholland@forcon.com.


FROM:
Your Name: E-Mail
Phone No: Fax No:
Company Name:
Address:
City: State: Zip Code

Claim or Policy No:
Date of Loss:

INSURED's INFORMATION:
Name:
Home Phone No: Work Phone No:
Cell Phone No:
Address:
City: State: Zip Code

CLAIM LOCATION INFORMATION
(If different from Insured's)
Contact:
Home Phone No: Work Phone No:
Cell Phone No:
Address:
City: State: Zip Code

DESCRIPTION OF EQUIPMENT DAMAGE
(Manufacturer, Model, Age, Etc. - Please submit as much information as possible)


Damaged Equipment has been:
Repaired
Replaced
Removed

Other

Present Location of Equipment:

SPECIAL INSTRUCTIONS OR COMMENTS:


When you Submit this form, you will receive a confirmation form on your web browser detailing what you have submitted to us. Please print that form as your confirmation. You will be e-mailed Forcon's case number and consultant's name for your reference.