RTS Inspection Order Form

Research Technical Services, Ltd.

Serving the Insurance Industry

Loss Control Inspection Request Form: You must click SUBMIT to send us your request.

Remember to PRINT the page for your records.

INSURANCE COMPANY NAME: *		RTS ACCOUNT#: *		REQUESTOR'S NAME: *

		POLICY #1: *				POLICY #2:

		INSURED OR BUSINESS NAME: *

		STREET ADDRESS

		CITY		STATE		ZIP CODE

		SURVEY ADDRESS

		CITY		STATE		ZIP CODE

		CONTACT'S NAME:		CONTACT'S PHONE:		TYPE?

		DUE DATE :				ORDER DATE :

		AGENT/AGENCY:		TELEPHONE:

		POLICY AMOUNT:		PROP.$:		LIAB.$:

		POLICY COVERAGE TYPE / BUSINESS TYPE / WORK PERFORMED: -Please specify the Type of Operation found at this location-

		INSURANCE BROKER: LIST INSURANCE COMPANY (CARRIER):

		SPECIAL ATTENTION / ADDITIONAL COMMENTS:

PHOTOS?

Front

Rear

Other

PHONE SURVEY:

Phone Survey

ADD REPLACEMENT COST:

Replacement Cost

		FULL SURVEY REPORTS		AUTOMOBILE/GARAGE

		PRODUCT SURVEY		SUPPLEMENTS

		SPECIFIED REPORT Multiperil (MP) & Property Only (PO)		LIABILITY SURVEY

		SMALL BUSINESS REPORTS		CLIENT SPECIAL

* Required to submit this form

Research Technical Services Ltd.
A Company Expanding the Service Role