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Emergency Contact Us Form
Type of Property
*
Residential
Commercial
Multistory Building
Company Name
Contact Name
*
#2 Contact Name
Address of Loss Site
*
Unit#
City
*
State
*
Zip
*
Phone #
*
Ext #
Other Phone #
Cell Phone #
Fax #
E-mail Address
*
Is this loss covered by your Insurance?
Yes
No
Unsure
Insurance/Billing Information (If known)
Insurance Company
Adjuster/Agent
Address
Claim#
Phone #
Fax #
E-mail Address
Type of service requested?
*
Water Damage
Fire Damage
Mold
Air Duct Cleaning
Carpet Cleaning
Other Service requested?
How did you come to call our company?
*
Prior
Insurance Co
Yellow Pages
TV
Friend
Website
Where did the water come from?
Sump Pump/Drain backup
Broken Pipe
Seepage
Roof leak
Other
What area(s) were affected?
Basement
Crawlspace
1st Floor
2nd Floor
Multifloors
Whats the approx square feet of all areas affected?
0 - 250 sqft
250 - 500 sqft
500 - 1500 sqft
1500 sqft
What type of floor was affected? (click all that apply)
Concrete
Carpet/padding
Tile
Wood
Gravel Crawlspace
Is the area(s) occupied/livable?
Yes
No
Is there standing Water?
Yes
No
Additional Comments/Notes