Individuals or Businesses Initial Damage Reporting
Please complete one survey per property address.
Reporting Individual (Owner or Renter)
Select
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First Name
Last Name
Property Street Address
City
Zip Code
Contact Phone Number
Contact Email
Building Type
PS - Primary Single Family
PM - Primary Mobile Home
PMF - Primary Multi Family Dwelling
SSH - Secondary Single Family (Vacation Home)
SMH - Secondary Mobile Home (Vacation Home)
RS - Rental Single Family
RMH - Rental Mobile Home
RMF - Rental Multifamily Dwelling
RB - Rental Business/Commercial
CM - Commercial
OTH - Shop
OTH - Barn
OTH - Outbuilding
OTH - Other
Does the property have a basement?
Yes
No
Primary Insurance Policy Type
Please select all that apply
Select or enter value
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Is your house/property inaccessible?
No
Yes
Damage Category
A - Affected (but still livable)
MN - Minor
MJ - Major
D - Destroyed
O - Other (make note in description of damages)
What caused the damage?
Please select all that apply
Select or enter value
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Description of damages
Estimated Damage Amount
Send me a copy of my responses
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