Storm Related Damage
Assessment Report
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Date
*
-
Month
-
Day
Year
Date
Type of Property
*
Single Family
Multi Family
Business
Construction Type
*
Masonry
Wood Frame
Mobile Home
Manufactured
Other
Please specify construction type if you choose other option
Source of Damages
*
Sewer Backup
Primarily Flood
Wind / Wind driven rain
Tornado
Other
Please specify source of damages if you choose other option
Degree of Damage
*
Minor
Major
Destroyed
Where did the damage occur?
*
Describe the Damage
*
Upload a photo of the damage
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