Emergency Service Form If you need to report a loss, please fill out the information below and our 24/7 Response Team will contact you shortly. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is this a commercial property?* Yes No Business Name (Optional) Phone*Loss Date* MM slash DD slash YYYY Loss Time : Hours Minutes AM PM AM/PM Has the source of the damage been fixed?* Yes No Loss Type*MoldFireSmokeWaterSewageOdorCleaning/Non-RestorationOtherCause of Loss*AC LeakAnimalBurglaryCandleDishwasherDryerFloodGreaseHot water heaterIce stormLightningMildewOtherOther applianceOther weatherPipePuff back-FurnaceRefridgeratorRoof leakSewage back-upSootStove/ovenSump pump failureToiletUnknownWashing machineWindComments