2. Initial Damage Assessment Report

4. First Name of Owner*
5. Last Name of Owner*
7. Number and Street of Property*
8. Owner's Email*
10. Cell Phone*
11. Home Phone
12. Work Phone
14. Type of Property

    1. Single Family

    1. Multi-Family( Usually Apts)

    1. Business

    1. Vacation Home-Not Primary Home
16. Ownership

    1. Rent

    1. Own

    1. Lease (Business Only)
18. Construction Type

    1. Masonry
    2. Wood Frame

    1. Mobile Home

    1. Manufactured

    1. Other
20. Damages(check all that apply)

    1. HVAC
    2. Water Heater
    3. Natural Gas (On)
    4. Natural Gas (Off)

    1. Electricity (On)
    2. Electricity (Off)
    3. Foundation

    1. Windows
    2. Sewer
    3. Furnace

    1. Major Appliances
    2. Roof Impact
    3. Other
22. Water Depth (in feet)
23. Basement
24. 1st Floor
25. 2nd Floor
27. Source of Damages (check all that apply)

    1. Sewer Backup
    2. Primarily Flood

    1. Wind/Wind Driven Rain

    1. Tornado

    1. Other
29. Type of Damage

    1. Minor
    2. Major
    3. Destroyed
30. Based on the Damages, the property is currently:

    1. Habitable
    2. Uninhabitable
32. Estimate of Damages
33. Repairs
34. Contents
35. Total
37. Comments
39. Full Name
40. Todays Date
    Todays Date
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42. 1. Receive an email copy of this form.
43. Email address

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44. Submit

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