Disaster Damage Estimate Form

Personal Information (all fields are required):

Type of Report *

Business

Residence

Address (where damage occurred): *

Mailing Address (if different): *

City *

State *

Zip *

Do you own or rent the property where the damage occurred? *

Own

Rent

Damage Information

Estimated Pre-Disaster Fair Market Value of the Structure: *

Estimated Structure Loss in Dollars: *

Estimated Property Loss in Dollars: *

Primary Cause of Damage? *

Date Damage Occurred: * +

Type of Insurance: *

Deductible Amount: *

Number of days business was closed due to disaster: *

Do you have Business Continuity Insurance? *

Yes

No

Is the property habitable? *

Yes

No

Is the property accessible? *

Yes

No

Please choose a damage category *

Destroyed - Total Loss, Permanently Uninhabitable

Major - Significant or Structural, more than 50% value, Uninhabitable

Minor - Conditional use, repairable in under 30 days

Affected - Living unit damaged, but still inhabitable

Description of damages: * 🛈

Contact Name *

Contact Phone *

Contact Email *