2. Contact Information
4. First Name*
5. Last Name*
7. Business Name (If Applicable)
9. City
10. State
12. Zip Code
13. Country
17. Damage Location
19. Street Address*
21. Address Line 2
23. City*
24. State*
26. Zip Code
27. Country
29. Additional Directions To Damaged Area (if any)
33. Damage Information
34. Date Damage Occurred (MM/DD/YYYY)*
    Date Damage Occurred (MM/DD/YYYY)
36. Property Type*
    -- Select One --Single FamilyMulti-FamilyBusinessNon-Primary ResidenceCounty PropertyState PropertyFederal Property
37. Ownership
    -- Select One --OwnRentLease - Business Only
39. Construction Type
    -- Select One --MasonryWood FrameManufacturedUnknown/Other
40. Insurance Type
    -- Select One --HomeownerRentalFlood (Structure)Flood (Contents)BusinessNone
42. Damage Source

    1. Flood Water
    2. Rain
    3. Wind\Tornado
    4. Hail
    5. Other
43. Flood Damage

    1. Less than 18" of water in first floor living area
    2. 18" or more of water in first floor living area
45. Structural Damage

    1. Broken windows
    2. Windows or doors blown in
    3. Interior flooring with some damage
    4. Exterior walls with some damage
    5. Extensive wall damage or walls missing
    6. Large portions of the roof is missing
    7. Major debris penetrating roof
    8. Dwelling in imminent danger; slide or erosion
    9. The dwelling has shifted off its foundation
    10. Complete failure of major structural components
46. Other Damages

    1. HVAC
    2. Water Heater
    3. Electricity
    4. Natural Gas
    5. Roof
    6. Foundation
    7. Windows
    8. Sewer
    9. Major Appliances
    10. Frame/Structure
    11. Furnace
47. Current Property State (given damages reported)

    1. Habitable
    2. Habitable with repairs
    3. Uninhabitable
49. Damage Description*
51. Damage Cost Estimate ($)
55. Attach Images of Damage (Accepted formats: PNG, JPG/JPEG)
57. Image of Damage #1
58. Image of Damage #2
60. Image of Damage #3
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

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