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Residential / Business Detailed Damage Assessment

  1. Residential / Business Detailed Damage Assessment

    Please fill this out to the best of your ability. If you are unable to determine a cost estimate, please leave blank.

  2. SECTION I: Resident / Occupant Information

  3. SECTION II: Property Owner / Landlord Information (If Different than Occupant)

  4. SECTION III: Habitability / Displacement Information

  5. Number of Occupants Displaced / Number of Days expect to be Displaced

  6. Disposition

  7. If staying with friends / relatives, in a hotel / motel, or a public shelter, please provide name and address.

  8. SECTION IV: Personal Property Losses

  9. Insurance

    Check all that apply: I have........

  10. May include estimate if available

  11. SECTION V: Property Damage

  12. Check One:

  13. Type of Damage

  14. Please include a "best guess" estimate of each damaged component if possible.

  15. The Damaged Property is:

  16. SECTION VI: Agricultural Damage / Losses

  17. Agricultural Damage / Lossses

  18. Include Type / Number of Livestock and Cost Estimate. Include Crop Type / Acres affected and Cost Estimate. Include Building / Structure Type and Cost Estimate.

  19. Any pictures or additional information, please attach files.

  20. Leave This Blank:

  21. This field is not part of the form submission.