Emergency Repair Request Form

EMERGENCY REPAIR REQUEST FORM

Use this form to report conditions that present an immediate threat to life, health, safety, or imminent significant property damage. Complete all applicable fields. Submitting this request constitutes an authorization for the building manager or authorized contractor to enter the premises as described below to assess and, if necessary, perform emergency repairs consistent with the authorization selected.

Requestor Information

Incident Details

Date incident discovered:   Time:

Reported to emergency services (if applicable): Yes No   If yes, agency/incident number:

Water leak / flooding    Gas leak    Electrical hazard    No heat (extreme conditions)    Structural collapse / collapse risk    Sewer backup    Fire or smoke damage    Other:

Access & Authorization

Occupant present at time of report: Yes No

I authorize entry by building management or authorized contractors to perform emergency repairs. I do not authorize entry unless accompanied by me.

I authorize the following immediate measures if necessary to prevent further damage or hazard (check all that apply):
Shut off water supply    Shut off gas supply    De-energize electrical circuits    Board up openings / secure property    Other:

If the estimated emergency repair cost is less than: $ , I authorize immediate repairs without prior approval from me.
I understand that I will be notified of costs and any charges will be processed in accordance with existing lease or contractual obligations.

Acknowledgements and Liability

By submitting this Emergency Repair Request, I certify that the information provided is true and accurate to the best of my knowledge. I acknowledge that building management will take reasonable steps to mitigate the emergency and that any temporary measures taken to prevent further damage may cause alteration to finishes or fixtures.

I understand that if the emergency was caused by my negligence or the negligence of my guests, I may be responsible for costs of repair and associated fees. I agree to indemnify and hold harmless the property owner and management for damage caused by factors outside of their control, except where law or contract provides otherwise.

Personal property loss or damage should be reported separately; submission of this form is not a waiver of any rights to file claims for damages.

For Office Use Only

Dispatch Date:   Dispatch Time:

Completion Date:   Completion Time:

Privacy & Records

Information provided on this form will be retained in the property management maintenance records. Contact information and incident details will be used only to coordinate emergency response and repairs and as otherwise permitted by applicable law.

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