Loss Draft Inspection

Client: ______________________________

Loan #: ______________________________ Appointment Due By: _______________

Borrower Name: ___________________________________________________________________

Address: _________________________________________________________________________

Residence Phone: ______________________ Business Phone: ____________________

Photo Instructions: __________________________________________________________________

Type of Loss: _____________________________________________________________________

Amount of Loss: ___________________________________________________________________

Special Instructions: _________________________________________________________________

_________________________________________________________________________________

Percentage of Repairs Completed: _____________________

Describe what repairs have been completed: _______________________________________________

__________________________________________________________________________________

Describe what repairs remain: __________________________________________________________

__________________________________________________________________________________

Inspector represents that the above information is, to the best of Inspector's knowledge and belief, true and complete as of the date the report is

signed, inspector also acknowledges that Quantum Facs inc. will rely upon the truth and completeness of the information as represented by

inspector in its dealings with other parties.

Date inspected: ____________________ Time inspected: _________________ Rep: ____________

Mortgager Signature: _____________________________ Inspector Signature: ___________________