Assessment Form Homeowner Name Email Telephone Street City State Zip Restoration Inspector Restoration Company Name Inspector Name Inspector Email Claim # Carrier CHUBB Adjuster Name Plumber Name Telephone Street City State Zip Installation will be IndoorOutdoor If Outdoor, LDS must be housed in a protective enclosure 18" above grade. Plumber providing protective cover? YesNo PSI Water Source CityWell Relays needed for pump YesNo Pipe Size where installed .75"1"1.25"1.5"2"2.5"3" Pipe orientation where installed HorizontalVertical Direction of water flow UpDown Secondary structures plumbed from the main Guest HousePool HouseOther Will second LDS be required for secondary structure? YesNo Pipe Size where second LDS will be installed .75"1"1.25"1.5"2"2.5"3" Panel & Power (discuss with homeowner) Control Panel should be installed 50' or less from the valve. Connecting to the web-based app? YesNo Type/Model of WiFi router? Connecting to a security system? YesNo Name of Security Company Outlets available for the valve and panel? YesNo Distance to non-switched, non-GFI outlet for valve: Electrician needed? YesNo Please explain the electrical work that will be required Water Features (check all that apply and provide details) Irrigation? YesNo LDS installed after irrigation? YesNo Make/Model of Controller Hose bibs? YesNo LDS installed after hose bibs? YesNo Fire Sprinkler? YesNo LDS must be installed after fire sprinkler. Pool/Hot-Tub? YesNo How is the pool/hot-tub filled? ManualAuto-Fill Put the Leak Defense System in Standby Mode when manually filling a pool LDS installed after pool/hot-tub? YesNo Irrigation timer to be added? YesNo Pond/Fountain? YesNo How is the pond/fountain filled? ManualAuto-Fill LDS installed after pond/fountain? YesNo # of gas water heaters Gas water heater make/model # of electric water heaters Electric water heater make/model Expansion tanks? YesNo Central boiler? YesNo Central boiler has low water cutoff? YesNo Radon bubbler? YesNo LDS must be installed after radon bubbler. Water mister? YesNo Humidifiers? YesNo LDS installed after humidifiers? YesNo Quantity of steam humidifiers Quantity of evaporative humidifiers Filter/Softener? YesNo LDS installed after filter/softener? YesNo Cartridge or regenerating? CartridgeRegenerating Filter/softener make and model Picture of inside of filter/softener head cover Recirculation pump? YesNo Circ pump switch needed? YesNo Circ pump hardwired or plugged in? HardwiredPlugged in Standalone ice machine? YesNo Ice machine make and model Ice machine gallons per day Reverse osmosis? YesNo Reverse osmosis monitored by LDS? YesNo Reverse osmosis whole house or under counter? Whole HouseUnder Counter LDS cannot be installed before whole house RO. Please call to discuss options: Split System / Install After. Reverse osmosis make and model Reverse osmosis # of fixtures Point of Leak Detectors (POLDs) # of POLDs without cable # of POLDs with 2' cables # of POLDs with 5' cables # of POLDs with 10' cables Primary Contact (if different from above) Primary Contact Name Primary Contact Email Δ
