Repairs & Maintenance Form

REPAIRS & MAINTENANCE INSURANCE FORM
Date*

MonthDayYear
Date
Address*
This form is to be completed monthly so that our maintenance crew can provide necessary maintenance/repairs.
Living Room: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Family Room: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Dining Room: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Kitchen: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Laundry Room: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Bedrooms: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is and specify the bedroom location
Exterior: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Plumbing: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Electrical: In good working order: If you checked NO above, please describe in detail what the concern is:

YesNo
If you checked NO above, please describe in detail what the concern is
Submitted By*
FOR INTERNAL USE What repair/maintenance was performed and by Who?
Should be Empty: