2. 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.
4. SECTION I: Resident / Occupant Information
6. First Name
7. Last Name
9. Address1
11. Address2
13. City
14. State
15. Zip
17. Home Phone
18. Cell Phone
19. Work Phone
21. SECTION II: Property Owner / Landlord Information (If Different than Occupant)
23. First Name
24. Last Name
26. Address1
28. Address2
30. City
31. State
32. Zip
34. Home Phone
35. Work Phone
37. SECTION III: Habitability / Displacement Information
39. Is the residence habitable (safe and sanitary)
    -- Select One --Yes (Skip this section)No (Complete this section)

    Key criteria: SAFE and SANTARY Guidelines: Are conditions livable? Has disaster interrupted utility services such as water, sewer, power, heat/AC? Is the structure stable? Are there other circumstances that make it unsafe or unsanitary to continue living there?
40. Displacement
    Number of Occupants Displaced / Number of Days expect to be Displaced
42. Disposition

    1. Staying with friends / relatives
    2. Staying in public shelter
    3. Staying in hotel / motel
    4. Relocated to / secured temporary residence
    5. Relocated to / secured new permanent residence
    6. Still living in home that is not habitable
    7. Don't have a place to stay
43. Location
    If staying with friends / relatives, in a hotel / motel, or a public shelter, please provide name and address.
45. SECTION IV: Personal Property Losses
47. Insurance

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

    1. No Insurance
    2. Homeowners / Renters Insurance
    3. Flood Insurance
48. Description of Personal Property Losses
    May include estimate if available
50. SECTION V: Property Damage
52. Check One:

    1. Residential Damage

    1. Business Damage
54. Type of Damage

    1. Structural Damage to Home / Business (exterior and interior)
    2. Furnace / Air Conditioner
    3. Sewer / Septic System / Water / Utility / Well
    4. Clean / Sanitize Expense
    5. Replace Carpeting
    6. Access to Dwelling (Driveway / bridge, ramp, etc)
    7. Other
56. Description of Property Damage
    Please include a "best guess" estimate of each damaged component if possible.
58. The Damaged Property is:

    1. A Primary / Full-time Residence

    1. A Summer / Vacation Home or Cabin

    1. Other (explain)
60. SECTION VI: Agricultural Damage / Losses
62. Agricultural Damage / Lossses

    1. Livestock

    1. Crops

    1. Building / Structures
64. Cost estimates
    Include Type / Number of Livestock and Cost Estimate. Include Crop Type / Acres affected and Cost Estimate. Include Building / Structure Type and Cost Estimate.
66. Pictures / Additonal Info
    Any pictures or additional information, please attach files.
68. Additional Info
70. Additional Info
72. Additional Info
74. Additional Info
76. Additional Info
78. Additional Info
80. Additional Info
82. Additional Info
84. Additional Info
86. Additional Info
88. Additional Info
90. Additional Info
92. Additional Info
Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field