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Preliminary Damage Assessment
This form is to help local government assess the damage and report the findings to the State and Federal authorities. Please answer each question honestly and with as much detailed as allowed.
Name (First and Last) *
Your answer
Name of Person Filling Out Form (if Different Than Name of Property Owner/Renter)
Your answer
Phone Number *
Your answer
Street Address of Damaged Property *
Your answer
City *
Your answer
Zip Code *
Your answer
Is this property residential or commercial? *
Do you own or rent this property? *
How is the property insured? *
Do you currently have homeowner's insurance, but the policy does not cover water damage due to flooding from the exterior of the home? *
Is this property a second home? *
Please select the answer that most closely describes your property: *
Are you classified as "low income" by state or federal standards? *
If there is water damage, please describe the depth and to what level of your property the water damage was sustained (basement, first floor, second floor). If you have no water damage, please respond, "N/A" *
Your answer
Please describe any damage (other than water) that your property sustained. If you have no additional damage, please respond, "N/A".
Your answer
Please check the answer that most closely describes the damage to your property: *
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