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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.