emergency-restorationl-form

Emergency Restoration & Environmental Services Request

Contact information

Full Name *

Phone (Primary) *

Secondary Phone (Optional) *

Email Address *

Property Information

Property Address *

City

State/Province

ZIP / Postal Code

Country

Property Address *Single-Family ResidentialMulti-FamilyCommercialIndustrialRental Property Is the property currently occupied?YesNo

Type of Incident

Select all that apply: *Water DamageFire / Smoke DamageStorm DamageSewage / Category 3 WaterMold Growth SuspectedConfirmed MoldTrauma / BiohazardOdor Issue (OCT)Unknown Contamination

Emergency Status

Is this an active emergency? *Yes – Water actively flowingYes – Fire damage within 24 hoursYes – Sewage backup presentYes – Biohazard presentNo – Damage occurred previously

Date *

Has the source of damage been stopped? *YesNoUnknown

Insurance Information (If Applicable)

Insurance Carrier *

Claim Number (If Available) *

Has an adjuster inspected? *YesNoPending

Affected Areas

Select impacted areas: *RoofAtticWallsCeilingFlooringCrawlspaceBasementHVAC SystemEntire Structure

Estimated square footage affected (if known): *

Environmental & Safety Disclosure

Are any of the following present? *Standing waterSewage contaminationVisible mold growthStrong smoke odorStructural instabilityBlood or bodily fluidsHazardous materialsElectrical hazardsUnknown contaminants

Has anyone experienced respiratory or health symptoms? *YesNo

Documentation Upload

Upload photos or existing documentation: *

No file chosen

Authorization & Acknowledgment

I authorize Diamond Height LLC to evaluate the reported conditionsI understand emergency mitigation may require immediate containment, removal, or stabilization measures.I acknowledge this request does not guarantee insurance coverageI understand hazardous or contaminated environments may require controlled access.I authorize contact regarding scheduling and next steps

Signature (Typed Name) *