Eaton Fire: Damages Questionnaire

II. REAL PROPERTY DAMAGE

A. PROPERTY IDENTIFICATION
1. Are you submitting a claim for Real Property damage? If Yes, answer Questions 2-24. Otherwise, skip to Section III. If you have multiple Loss Locations, complete Sections II.A-H for each loss location.
1A: How many loss locations are you claiming?*
2. Loss Location #1

Street Address

Street Address Line 2

CityState and Zip Code

APN (if known)
3. Provide a brief description of the damaged real property and produce documents, including photos or videos, supporting your claim, including records reflecting ownership of real property and any improvements to the property that existed at the time.
4. At the time of the Fire, were you a title owner of this property?
If yes, list all title owners at the time of the Fire:
If no, since the Fire, have you received an assignment of the right to make a claim related to the damage of this real property?
If you received an assignment, submit relevant documents reflecting the assignment.
5. On what date did you purchase the property?

MonthDayYear
Date
6. What was the purchase price when you purchased the property?
7. At the time of the fire, was the property your household's primary residence?
8. What is the size of the parcel on which this property is located? ANSWER IN SQUARE FEET OR BY ACRES AND CLARIFY.
9. Do you still own the Real Property that was affected by the Fire? If Yes, answer questions 10-13. If No, answer Question 14.
10. Have you fully repaired or completely restored the property since the fire?
If Yes, indicate the completion date: Date
11. Did you list the property for sale in the five years before the fire?
If yes, state the asking price for the property and the amount of any offers you received to purchase the property: Asking price & any offers
12. Estimated or actual cost of repairing or rebuilding the real property:
If you have documents, including photos or videos, identifying the cost to repair or replace the dwelling, you must produce them.
13. Do you have a genuine desire to repair or restore this property?
14. Did you sell this property after the Fire? If Yes, provide the date of sale and price received.

MonthDayYear
Date
Price Received:
15. Has this property been listed for sale since the Fire? If Yes, answer questions 16-17. If No, skip to question 18.
16. Provide the date the property was listed for sale, the asking price, and the amount of any offers you received to purchase the property.
17. Do you still intend to sell the property?
18. Do you have an estimate of the value of your property within a month BEFORE the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
19. Do you have an estimate of the value of your property within a month AFTER the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
20. Have you hired a third party to remove debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
21. Have you hired a third party to remove anything OTHER than debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
22. In the five years prior to the fire, have you cleared brush on your property?
If Yes, describe:
23. In the five years prior to the fire, have you cleared trees on your property?
If Yes, describe:
24. Was any portion of your property constructed with fire resistant building materials?
If Yes, describe:

2. Loss Location #2

Street Address

City

StateZip Code

APN (if known)
3. Provide a brief description of the damaged real property and produce documents, including photos or videos, supporting your claim, including records reflecting ownership of real property and any improvements to the property that existed at the time.
4. At the time of the Fire, were you a title owner of this property?
If yes, list all title owners at the time of the Fire:
If no, since the Fire, have you received an assignment of the right to make a claim related to the damage of this real property?
If you received an assignment, submit relevant documents reflecting the assignment.
5. On what date did you purchase the property?

MonthDayYear
Date
6. What was the purchase price when you purchased the property?
7. At the time of the fire, was the property your household's primary residence?
8. What is the size of the parcel on which this property is located? ANSWER IN SQUARE FEET OR BY ACRES AND CLARIFY.
9. Do you still own the Real Property that was affected by the Fire? If Yes, answer questions 10-13. If No, answer Question 14.
10. Have you fully repaired or completely restored the property since the fire?
If Yes, indicate the completion date: Date
11. Did you list the property for sale in the five years before the fire?
If yes, state the asking price for the property and the amount of any offers you received to purchase the property: Asking price & any offers
12. Estimated or actual cost of repairing or rebuilding the real property:
If you have documents, including photos or videos, identifying the cost to repair or replace the dwelling, you must produce them.
13. Do you have a genuine desire to repair or restore this property?
14. Did you sell this property after the Fire? If Yes, provide the date of sale and price received.

MonthDayYear
Date
Price Received:
15. Has this property been listed for sale since the Fire? If Yes, answer questions 16-17. If No, skip to question 18.
16. Provide the date the property was listed for sale, the asking price, and the amount of any offers you received to purchase the property.
17. Do you still intend to sell the property?
18. Do you have an estimate of the value of your property within a month BEFORE the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
19. Do you have an estimate of the value of your property within a month AFTER the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
20. Have you hired a third party to remove debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
21. Have you hired a third party to remove anything OTHER than debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
22. In the five years prior to the fire, have you cleared brush on your property?
If Yes, describe:
23. In the five years prior to the fire, have you cleared trees on your property?
If Yes, describe:
24. Was any portion of your property constructed with fire resistant building materials?
If Yes, describe:

Loss Location 3
2. Loss Location #3

Street Address

City

StateZip Code

APN (if known)
3. Provide a brief description of the damaged real property and produce documents, including photos or videos, supporting your claim, including records reflecting ownership of real property and any improvements to the property that existed at the time.
4. At the time of the Fire, were you a title owner of this property?
If yes, list all title owners at the time of the Fire:
If no, since the Fire, have you received an assignment of the right to make a claim related to the damage of this real property?
If you received an assignment, submit relevant documents reflecting the assignment.
5. On what date did you purchase the property?

MonthDayYear
Date
6. What was the purchase price when you purchased the property?
7. At the time of the fire, was the property your household's primary residence?
8. What is the size of the parcel on which this property is located? ANSWER IN SQUARE FEET OR BY ACRES AND CLARIFY.
9. Do you still own the Real Property that was affected by the Fire? If Yes, answer questions 10-13. If No, answer Question 14.
10. Have you fully repaired or completely restored the property since the fire?
If Yes, indicate the completion date: Date
11. Did you list the property for sale in the five years before the fire?
If yes, state the asking price for the property and the amount of any offers you received to purchase the property: Asking price & any offers
12. Estimated or actual cost of repairing or rebuilding the real property:
If you have documents, including photos or videos, identifying the cost to repair or replace the dwelling, you must produce them.
13. Do you have a genuine desire to repair or restore this property?
14. Did you sell this property after the Fire? If Yes, provide the date of sale and price received.

MonthDayYear
Date
Price Received:
15. Has this property been listed for sale since the Fire? If Yes, answer questions 16-17. If No, skip to question 18.
16. Provide the date the property was listed for sale, the asking price, and the amount of any offers you received to purchase the property.
17. Do you still intend to sell the property?
18. Do you have an estimate of the value of your property within a month BEFORE the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
19. Do you have an estimate of the value of your property within a month AFTER the fire?
If yes, state the value and whether you obtained this value via appraisal, your own estimate, or another way.
20. Have you hired a third party to remove debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
21. Have you hired a third party to remove anything OTHER than debris from your property after the fire?
If Yes, describe what was done: Description If Yes, what was total cost: Price
22. In the five years prior to the fire, have you cleared brush on your property?
If Yes, describe:
23. In the five years prior to the fire, have you cleared trees on your property?
If Yes, describe:
24. Was any portion of your property constructed with fire resistant building materials?
If Yes, describe:

II. Real Property Damage continued.

D. OTHER STRUCTURES/OUTBUILDINGS
1. Does your property claim include other structures (i.e. barn, detached garage, outbuilding, shed) that were damaged or destroyed by the fire? If Yes, answer Questions 2-9 for each structure. Otherwise skip to Section II.E.
Loss Location #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Please describe the type of structure(s)
3. Describe the composition of the roof (wood, metal, asphalt, ceramic tiles, etc.):
4. What was the size of each other structure? In square feet.
5. Provide date when other structure constructed?
If unknown, input "unknown."
6. If not destroyed, description of the damage:
7. If your other structure was partially damaged, how much have you been professionally quoted or paid to repair the structure? If this amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to repair the structure, you must produce them.
8. If your other structure was destroyed, how much have you been professionally quoted or paid to repair the structure? If this amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to repair the structure, you must produce them.
9. For each other structure, did it have any of the following? Check all that apply

ElectricityPermanent FoundationPlumbing
Add a structure?

YesNo
2. Please describe the type of structure(s)
3. Describe the composition of the roof (wood, metal, asphalt, ceramic tiles, etc.):
4. What was the size of each other structure? In square feet.
5. When was each other structure constructed?

MonthDayYear
Date
6. If not destroyed, description of the damage:
7. If your other structure was partially damaged, how much have you been professionally quoted or paid to repair the structure? If this amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to repair the structure, you must produce them.
8. If your other structure was destroyed, how much have you been professionally quoted or paid to repair the structure? If this amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to repair the structure, you must produce them.
9. For each other structure, did it have any of the following? Check all that apply

ElectricityPermanent FoundationPlumbing

II. Real Property Damage continued.

E. AMENITIES
Input Loss Location #1

Street Address

Street Address Line 2

CityState

Zip Code
1. Does your property claim include fencing? If Yes, answer Question 2. If no, skip to Question 3.
Answer all questions in relation to Loss Location #1
2. Describe the material, height, and approximate length of fencing.
If you have documents stating this information, you must produce them.
3. Does your property claim include a swimming pool? If Yes, answer Question 4. If no, skip to Question 5.
4. Describe the type and size of pool, and date of construction.
If you have any documents stating this information, you must produce them.
5. Does your property claim include any retaining walls? If Yes, answer Question 6. If no, skip to Question 7.
6. Describe the material, height, location and approximate length of retaining wall.
If you have any documents stating this information, you must produce them.
7. Does your property claim include any culverts? If Yes, answer Question 8. If no, skip to Question 9.
8. Describe the materials, location(s), and approximate size(s) of any culverts.
If you have any documents stating this information, you must produce them.
9. Does your property claim include solar panels? If Yes, answer Question 10. If no, skip to Question 11.
10. List the type of solar panels, the manufacturer, the size of the panels, the number of panels, the manufacturer of the inverter, the maximum system voltage, and the date of installation.
If you have any documents stating this information, you must produce them.
11. Does your property have any irrigation? If Yes, answer Question 12. If no, skip to Question 13.
12. Describe the type of irrigation, materials, and location on the property.
13. Did your property have a water well or tank? If Yes, answer Question 14. If no, skip to Question 15.
14. Describe the water well or tank and location on the property, including but not limited to: casting size, well depth, and gallons per minute.
15. If there were other amenities on your property that were destroyed or damaged, please describe those:
16. Do you claim damage to the above amenities to the property? IF YES, identify which amenities were damaged.
17. Did you install any of these amenities since purchasing the property? If yes, state the total cost you paid for the amenities
Cost:
18. If any of your amenities were partially damaged, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.
19. If any of your amenities were destroyed, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.
Add a Loss Location?
Input Loss Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Does your property claim include fencing? If Yes, answer Question 2. If no, skip to Question 3.
Answer all questions in relation to Loss Location #2
2. Describe the material, height, and approximate length of fencing.
If you have documents stating this information, you must produce them.
3. Does your property claim include a swimming pool? If Yes, answer Question 4. If no, skip to Question 5.
4. Describe the type and size of pool, and date of construction.
If you have any documents stating this information, you must produce them.
5. Does your property claim include any retaining walls? If Yes, answer Question 6. If no, skip to Question 7.
6. Describe the material, height, location and approximate length of retaining wall.
If you have any documents stating this information, you must produce them.
7. Does your property claim include any culverts? If Yes, answer Question 8. If no, skip to Question 9.
8. Describe the materials, location(s), and approximate size(s) of any culverts.
If you have any documents stating this information, you must produce them.
9. Does your property claim include solar panels? If Yes, answer Question 10. If no, skip to Question 11.
10. List the type of solar panels, the manufacturer, the size of the panels, the number of panels, the manufacturer of the inverter, the maximum system voltage, and the date of installation.
If you have any documents stating this information, you must produce them.
11. Does your property have any irrigation? If Yes, answer Question 12. If no, skip to Question 13.
12. Describe the type of irrigation, materials, and location on the property.
13. Did your property have a water well or tank? If Yes, answer Question 14. If no, skip to Question 15.
14. Describe the water well or tank and location on the property, including but not limited to: casting size, well depth, and gallons per minute.
15. If there were other amenities on your property that were destroyed or damaged, please describe those:
16. Do you claim damage to the above amenities to the property? IF YES, identify which amenities were damaged.
17. Did you install any of these amenities since purchasing the property? If yes, state the total cost you paid for the amenities
Cost:
18. If any of your amenities were partially damaged, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.
19. If any of your amenities were destroyed, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.
Add a Loss Location?
Input Loss Location #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
1. Does your property claim include fencing? If Yes, answer Question 2. If no, skip to Question 3.
Answer all questions in relation to Loss Location #3
2. Describe the material, height, and approximate length of fencing.
If you have documents stating this information, you must produce them.
3. Does your property claim include a swimming pool? If Yes, answer Question 4. If no, skip to Question 5.
4. Describe the type and size of pool, and date of construction.
If you have any documents stating this information, you must produce them.
5. Does your property claim include any retaining walls? If Yes, answer Question 6. If no, skip to Question 7.
6. Describe the material, height, location and approximate length of retaining wall.
If you have any documents stating this information, you must produce them.
7. Does your property claim include any culverts? If Yes, answer Question 8. If no, skip to Question 9.
8. Describe the materials, location(s), and approximate size(s) of any culverts.
If you have any documents stating this information, you must produce them.
9. Does your property claim include solar panels? If Yes, answer Question 10. If no, skip to Question 11.
10. List the type of solar panels, the manufacturer, the size of the panels, the number of panels, the manufacturer of the inverter, the maximum system voltage, and the date of installation.
If you have any documents stating this information, you must produce them.
11. Does your property have any irrigation? If Yes, answer Question 12. If no, skip to Question 13.
12. Describe the type of irrigation, materials, and location on the property.
13. Did your property have a water well or tank? If Yes, answer Question 14. If no, skip to Question 15.
14. Describe the water well or tank and location on the property, including but not limited to: casting size, well depth, and gallons per minute.
15. If there were other amenities on your property that were destroyed or damaged, please describe those:
16. Do you claim damage to the above amenities to the property? IF YES, identify which amenities were damaged.
17. Did you install any of these amenities since purchasing the property? If yes, state the total cost you paid for the amenities
Cost:
18. If any of your amenities were partially damaged, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.
19. If any of your amenities were destroyed, how much have you been professionally quoted or paid to rebuild each of these amenities? If the amount(s) includes any upgrades, describe the upgrades:
If you have any documents, including photos or videos, identifying the cost to rebuild each amenity, you must produce them.

II. Real Property Damage continued.

F. FORESTRY/LANDSCAPING
1. Does your property claim include landscaping, shrubbery, vegetation, or forestry? If Yes, answer Questions 2-8. Otherwise, skip to Section II.G.
Input Loss Location #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Describe the type and quantity of landscaping, shrubbery, or vegetation that was damaged or destroyed.
3. Did property contain ornamental trees and landscaping damaged by the fire? IF YES, describe the type and age of the ornamental trees and landscaping. Include if total loss, partial loss, or smoke damage.
4. If your claim includes forestry damage, indicate the damaged or destroyed acreage.
5. Did you install or improve the landscaping after purchasing the property?
6. If you installed or improved the landscaping since purchasing the property, identify the cost you incurred before the fire to install or improve the landscaping.
7. How much have you been professionally quoted or paid to restore or replace damage to the forestry, landscaping, shrubbery, or vegetation? If the amount includes any upgrades, please describe upgrades:
If you have any documents, including photos or videos, identifying the cost to restore or replace the forestry, landscaping, shrubbery, or vegetation, you must produce them.
8. Did your property contain agriculture or livestock? If yes, please identify the amount and type, and any costs associated with damage to agriculture or livestock.
If you lost income from agriculture or livestock-related business, please include that amount in Section III or IV in the next pages.
Would you like to add a Loss Location?
Input Loss Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Describe the type and quantity of landscaping, shrubbery, or vegetation that was damaged or destroyed.
3. Did property contain ornamental trees and landscaping damaged by the fire? IF YES, describe the type and age of the ornamental trees and landscaping. Include if total loss, partial loss, or smoke damage.
4. If your claim includes forestry damage, indicate the damaged or destroyed acreage.
5. Did you install or improve the landscaping after purchasing the property?
6. If you installed or improved the landscaping since purchasing the property, identify the cost you incurred before the fire to install or improve the landscaping.
7. How much have you been professionally quoted or paid to restore or replace damage to the forestry, landscaping, shrubbery, or vegetation? If the amount includes any upgrades, please describe upgrades:
If you have any documents, including photos or videos, identifying the cost to restore or replace the forestry, landscaping, shrubbery, or vegetation, you must produce them.
8. Did your property contain agriculture or livestock? If yes, please identify the amount and type, and any costs associated with damage to agriculture or livestock.
If you lost income from agriculture or livestock-related business, please include that amount in Section III or IV in the next pages.
Would you like to add a Loss Location?
Input Loss Location #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Describe the type and quantity of landscaping, shrubbery, or vegetation that was damaged or destroyed.
3. Did property contain ornamental trees and landscaping damaged by the fire? IF YES, describe the type and age of the ornamental trees and landscaping. Include if total loss, partial loss, or smoke damage.
4. If your claim includes forestry damage, indicate the damaged or destroyed acreage.
5. Did you install or improve the landscaping after purchasing the property?
6. If you installed or improved the landscaping since purchasing the property, identify the cost you incurred before the fire to install or improve the landscaping.
7. How much have you been professionally quoted or paid to restore or replace damage to the forestry, landscaping, shrubbery, or vegetation? If the amount includes any upgrades, please describe upgrades:
If you have any documents, including photos or videos, identifying the cost to restore or replace the forestry, landscaping, shrubbery, or vegetation, you must produce them.
8. Did your property contain agriculture or livestock? If yes, please identify the amount and type, and any costs associated with damage to agriculture or livestock.
If you lost income from agriculture or livestock-related business, please include that amount in Section III or IV in the next pages.

III. PERSONAL PROPERTY CLAIMS
1. Does any part of your property claim relate to damage to personal property that you owned at the time of the Fire? Personal property includes the contents of your home such as furniture, clothing, and household items as well as automobiles and other movable property. If No, skip to Section III. If you have lost or damaged personal property at multiple Loss Locations, complete Section II.G. for each loss location.
Loss Location #1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. If you are asserting claims for damage to personal property, provide the following:

a. Identify the item of personal property:

b. Identify the quantity of each item:

c. Identify the manufacturer and model of each item, if applicable:

d. Identify the year that each item was purchased:
Input 2A,B,C,D Here:
You may provide this information by way of producing the personal inventory you provided to your insurer or prepared for this litigation, if it contains all of the information requested above.
3. Does your claim include any loss of an individual item or collection of a specific type of personal property that was valued at more than $10k?
4. If the answer to Question 3 is Yes, describe the item or collection including the results of any professional appraisals for the item or collection, if any.
If you have documents that detail this information, you must produce them.
5. Have you removed any personal property from your property after the fire? If so, describe what was removed.
6. Do you have a pet that was injured as a result of the Fire?
If yes, identify the type of pet and describe any treatment your pet received if it was injured in the fire including the cost and any insurance payments received for that treatment. If you have documents that detail this information, you must produce them.
7. What is the estimated value of your destroyed or damaged personal property?
Add another loss location personal property claim?

YesNo
Loss Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. If you are asserting claims for damage to personal property, provide the following:

a. Identify the item of personal property:

b. Identify the quantity of each item:

c. Identify the manufacturer and model of each item, if applicable:

d. Identify the year that each item was purchased:
Input 2A,B,C,D Here:
You may provide this information by way of producing the personal inventory you provided to your insurer or prepared for this litigation, if it contains all of the information requested above.
3. Does your claim include any loss of an individual item or collection of a specific type of personal property that was valued at more than $10k?
4. If the answer to Question 3 is Yes, describe the item or collection including the results of any professional appraisals for the item or collection, if any.
If you have documents that detail this information, you must produce them.
5. Have you removed any personal property from your property after the fire? If so, describe what was removed.
6. Do you have a pet that was injured as a result of the Fire?
If yes, identify the type of pet and describe any treatment your pet received if it was injured in the fire including the cost and any insurance payments received for that treatment. If you have documents that detail this information, you must produce them.
7. What is the estimated value of your destroyed or damaged personal property?
Add another loss location personal property claim?

YesNo
Loss Location #3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. If you are asserting claims for damage to personal property, provide the following:

a. Identify the item of personal property:

b. Identify the quantity of each item:

c. Identify the manufacturer and model of each item, if applicable:

d. Identify the year that each item was purchased:
Input 2A,B,C,D Here:
You may provide this information by way of producing the personal inventory you provided to your insurer or prepared for this litigation, if it contains all of the information requested above.
3. Does your claim include any loss of an individual item or collection of a specific type of personal property that was valued at more than $10k?
4. If the answer to Question 3 is Yes, describe the item or collection including the results of any professional appraisals for the item or collection, if any.
If you have documents that detail this information, you must produce them.
5. Have you removed any personal property from your property after the fire? If so, describe what was removed.
6. Do you have a pet that was injured as a result of the Fire?
If yes, identify the type of pet and describe any treatment your pet received if it was injured in the fire including the cost and any insurance payments received for that treatment. If you have documents that detail this information, you must produce them.
7. What is the estimated value of your destroyed or damaged personal property?

IV. OTHER PROPERTY DAMAGE
1. Did you suffer any property loss other than the real and/or personal property damage indicated above as a result of the Fire? If Yes, answer Questions 2-4 and provide documents supporting your claim. Otherwise, skip to Section V.
2. Provide a brief description of the damaged property.
3. If this other property was partially damaged, how much have you been professionally quoted or paid to repair this property? If the amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to rebuild the property, you must produce them.
4. If this other property was destroyed, how much have you been professionally quoted or paid to repair this property? If the amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to rebuild the property, you must produce them.
Add another loss location?

YesNo
Loss Location #2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Provide a brief description of the damaged property.
3. If this other property was partially damaged, how much have you been professionally quoted or paid to repair this property? If the amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to rebuild the property, you must produce them.
4. If this other property was destroyed, how much have you been professionally quoted or paid to repair this property? If the amount includes any upgrades, describe the upgrades:
If you have documents, including photos or videos, identifying the cost to rebuild the property, you must produce them.

V. BUSINESS INCOME LOSS
1. Are you submitting a claim for lost profits on behalf of a business affected by the Fire? If Yes, answer Questions 2-16. Otherwise, skip to Section VI. For purposes of classifying your claim, if you are a sole proprietor and you file your federal taxes on a Form 1040 with a Schedule C, E, or F that lists expenses, you are considered a business plaintiff for purposes of this Damages Questionnaire.
2. Does your claim for lost profits relate to a physical injury that you sustained as a result of the Fire?
3. Does your claim for lost profits relate to damage to property in which you had a property interest at the time of the Fire? If so, describe your interest in the property.
4. Business Address (provide address used on tax returns)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Provide a brief description of the business, including the industry it operates in.
6. Identify all owners of the business, their respective Taxpayer Identification Numbers and ownership interests. Provide full legal names. If an owner is not a natural person, identify the legal form of the entity (e.g., partnership)
7. Provide public business website URL
8. Provide the usernames and social media platforms your business accounts are on
9. Has the business permanently ceased operations and/or declared bankruptcy since the Fire? If Yes, enter the date the business ceased operations and/or declared bankruptcy.
MonthDayYear
Date
10. Was business at this Loss Location interrupted as a result of the Fire? If you have multiple Loss Locations, list all other loss locations for this business where business was interrupted:
11. Did you resume your business at this Loss Location, or if not, do you intend to resume your business at this Loss Location. Include the date/anticipated date of resuming operations. If you do not intend to reopen your business, state why. If multiple loss locations state if you intend to resume those businesses.
12. Identify the losses suffered at the Loss Locations.
13. Did your business at this Loss Location suffer any business income losses as a result of the fire? Answer for each Loss Location. If yes, provide the amount claimed, how that amount was calculated, the duration of time which the business income loss amount, and whether your business is impacted by annual seasonality.
14. Did your business at this Loss Location incur any additional remediation expenses as a result of the Fire? If Yes, provide the types and amounts claimed for additional remediation expenses (excluding insurance recovery). Answer for each Loss Location.
15. If your answer to Question 14 was Yes, provide the types and amounts claimed for temporary security, labor, water supply, utilities, and other mitigation steps (relocation, shipping, etc)
16. Provide any further information or explanation you would like to include regarding your business loss claim(s)
Add Loss Location?
2. Does your claim for lost profits relate to a physical injury that you sustained as a result of the Fire?
3. Does your claim for lost profits relate to damage to property in which you had a property interest at the time of the Fire? If so, describe your interest in the property.
4. Business Address (provide address used on tax returns)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Provide a brief description of the business, including the industry it operates in.
6. Identify all owners of the business, their respective Taxpayer Identification Numbers and ownership interests. Provide full legal names. If an owner is not a natural person, identify the legal form of the entity (e.g., partnership)
7. Provide public business website URL
8. Provide the usernames and social media platforms your business accounts are on
9. Has the business permanently ceased operations and/or declared bankruptcy since the Fire? If Yes, enter the date the business ceased operations and/or declared bankruptcy.
MonthDayYear
Date
10. Was business at this Loss Location interrupted as a result of the Fire? If you have multiple Loss Locations, list all other loss locations for this business where business was interrupted:
11. Did you resume your business at this Loss Location, or if not, do you intend to resume your business at this Loss Location. Include the date/anticipated date of resuming operations. If you do not intend to reopen your business, state why. If multiple loss locations state if you intend to resume those businesses.
12. Identify the losses suffered at the Loss Locations.
13. Did your business at this Loss Location suffer any business income losses as a result of the fire? Answer for each Loss Location. If yes, provide the amount claimed, how that amount was calculated, the duration of time which the business income loss amount, and whether your business is impacted by annual seasonality.
14. Did your business at this Loss Location incur any additional remediation expenses as a result of the Fire? If Yes, provide the types and amounts claimed for additional remediation expenses (excluding insurance recovery). Answer for each Loss Location.
15. If your answer to Question 14 was Yes, provide the types and amounts claimed for temporary security, labor, water supply, utilities, and other mitigation steps (relocation, shipping, etc)
16. Provide any further information or explanation you would like to include regarding your business loss claim(s)

VI. PERSONAL INCOME LOSS

(Lost Wages)
1. Does your claim for lost wages relate to a physical injury that you sustained as a result of the Fire?
Provide Plaintiff Name:
2. Does your claim for lost wages relate to damage to property in which you had a property interest at the time of the Fire?
3. Does your claim for lost wages relate to evacuation/and or displacement as a result of the Fire?
4. Does your claim for lost wages relate to damage to your employer's property as a result of the Fire?
5. Employer Information

Employer Name

Employer Address

Employer Telephone NumberState / Province

Employer Identification Number (EIN)
6. Employment Information.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
If you lost income from multiple sources, provide additional answers for each source.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
If you lost income from multiple sources, provide additional answers for each source.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
7. Do you claim you will continue to lose income or wages into the future? If yes, provide an estimate of the amount of lost future net income or wages, and how long you will be unable to work:
8. If you have not returned to your job at the time of the fire, have you obtained some over form of employment? If Yes, provide the following:

Current Employer

Employment Start Date:

Wage/SalaryState / Province

Employer Identification Number (EIN)
9. Please include below any further additional information or explanation regarding your lost wages claim.
Add a Plaintiff?

YesNo
1. Does your claim for lost wages relate to a physical injury that you sustained as a result of the Fire?
Provide Plaintiff Name:
2. Does your claim for lost wages relate to damage to property in which you had a property interest at the time of the Fire?
3. Does your claim for lost wages relate to evacuation/and or displacement as a result of the Fire?
4. Does your claim for lost wages relate to damage to your employer's property as a result of the Fire?
5. Employer Information

Employer Name

Employer Address

Employer Telephone NumberState / Province

Employer Identification Number (EIN)
6. Employment Information.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
If you lost income from multiple sources, provide additional answers for each source.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
If you lost income from multiple sources, provide additional answers for each source.

Employment Start Date

Employment End Date

Length of Time Out of WorkWage/Salary

Total Lost Wages:
7. Do you claim you will continue to lose income or wages into the future? If yes, provide an estimate of the amount of lost future net income or wages, and how long you will be unable to work:
8. If you have not returned to your job at the time of the fire, have you obtained some over form of employment? If Yes, provide the following:

Current Employer

Employment Start Date:

Wage/SalaryState / Province

Employer Identification Number (EIN)
9. Please include below any further additional information or explanation regarding your lost wages claim.

VII. EMOTIONAL DISTRESS

B. Substantial Interference with Use or Enjoyment of Property
State Plaintiff Name
1. Did you experience emotional distress or mental anguish from the loss of use or enjoyment of your property as a result of the Fire
2. If Yes, what was the address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If real property, indicate your relationship to the property
3. At the time of the fire, did you have the legal right to occupy the property?
Describe your relationship to the property at the time of the fire, including how often you occupied the property. (i.e did you live there full time?)
4. Were you displaced from this property as a result of the Fire?
If yes, provide the date you were displaced: Date
5. If you answered Yes to Question 4, have you resumed living at the property since you were displaced as a result of the Fire?
If yes, provide the date you resumed living at the property: Date
6. Did you lose sentimental or irreplaceable personal property in the Fire? If Yes, describe this personal property:
Add a Plaintiff?

YesNo
State Plaintiff Name
1. Did you experience emotional distress or mental anguish from the loss of use or enjoyment of your property as a result of the Fire
2. If Yes, what was the address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If real property, indicate your relationship to the property
3. At the time of the fire, did you have the legal right to occupy the property?
Describe your relationship to the property at the time of the fire, including how often you occupied the property. (i.e did you live there full time?)
4. Were you displaced from this property as a result of the Fire?
If yes, provide the date you were displaced: Date
5. If you answered Yes to Question 4, have you resumed living at the property since you were displaced as a result of the Fire?
If yes, provide the date you resumed living at the property: Date
6. Did you lose sentimental or irreplaceable personal property in the Fire? If Yes, describe this personal property:
State other Household Plaintiffs' Names here if all Information on page is identical and applicable to them:
Add a Loss Location?

YesNo
State Plaintiff Name
Second Loss Location if Applicable:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If real property, indicate your relationship to the property
3. At the time of the fire, did you have the legal right to occupy the property?
Describe your relationship to the property at the time of the fire, including how often you occupied the property. (i.e did you live there full time?)
4. Were you displaced from this property as a result of the Fire?
If yes, provide the date you were displaced: Date
5. If you answered Yes to Question 4, have you resumed living at the property since you were displaced as a result of the Fire?
If yes, provide the date you resumed living at the property: Date
6. Did you lose sentimental or irreplaceable personal property in the Fire? If Yes, describe this personal property:
State other Household Plaintiffs' Names here if all Information on page is identical and applicable to them:
Add a Loss Location?

YesNo
State Plaintiff Name
Third Loss Location if Applicable:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If real property, indicate your relationship to the property
3. At the time of the fire, did you have the legal right to occupy the property?
Describe your relationship to the property at the time of the fire, including how often you occupied the property. (i.e did you live there full time?)
4. Were you displaced from this property as a result of the Fire?
If yes, provide the date you were displaced: Date
5. If you answered Yes to Question 4, have you resumed living at the property since you were displaced as a result of the Fire?
If yes, provide the date you resumed living at the property: Date
6. Did you lose sentimental or irreplaceable personal property in the Fire? If Yes, describe this personal property:

VIII. PERSONAL INJURY
1. As a result of the Fire, did you suffer a personal injury? In this context, personal injury means a physical bodily injury or mental health condition resulting from the Fire.
State Plaintiff Name:
2. Did the injury require hospitalization?
3. Injury Types:
4. Injury Date:

MonthDayYear
Date
5. Medical Provider/Facility:
6. Treatment Start Date:

MonthDayYear
Date
7. Treatment End Date:

MonthDayYear
Date
8. Description of Treatment:
9. State the dollar value of your claim for medical billings to date:
10. Describe any ongoing treatment:
11. If you have been diagnosed with or treated for the same medical or mental health condition in the five years prior to the fire, please describe:
12. Are you seeking reimbursement for medical or mental health treatment? If Yes, state the amount claimed:
If you have documents stating this information, including bills, receipts, or statements, you must produce them.
Additional Injuries:
Add Plaintiff?

YesNo
State Plaintiff Name:
2. Did the injury require hospitalization?
3. Injury Types:
4. Injury Date:

MonthDayYear
Date
5. Medical Provider/Facility:
6. Treatment Start Date:

MonthDayYear
Date
7. Treatment End Date:

MonthDayYear
Date
8. Description of Treatment:
9. State the dollar value of your claim for medical billings to date:
10. Describe any ongoing treatment:
11. If you have been diagnosed with or treated for the same medical or mental health condition in the five years prior to the fire, please describe:
12. Are you seeking reimbursement for medical or mental health treatment? If Yes, state the amount claimed:
If you have documents stating this information, including bills, receipts, or statements, you must produce them.
Additional Injuries:

IX. ADDITIONAL LIVING EXPENSES
1. Did you relocate from your residence as a result of the Fire?
If yes, answer the questions below. Otherwise skip to Section X.
State Plaintiff Name
2. Provide the location(s) to which you relocated and the approximate date(s) when your relocated.
3. Did you have any additional costs associated with relocating? If yes, please describe those additional costs and identify the amount.
4. Did you incur any other out-of-pocket expenses as a result of displacement from the Fire? If Yes, indicate the types and total amount of each for out-of-pocket-expense:
Add a Plaintiff?

YesNo
State Plaintiff Name
1. Did you relocate from your residence as a result of the Fire?
If yes, answer the questions below. Otherwise skip to Section X.
2. Provide the location(s) to which you relocated and the approximate date(s) when your relocated.
3. Did you have any additional costs associated with relocating? If yes, please describe those additional costs and identify the amount.
4. Did you incur any other out-of-pocket expenses as a result of displacement from the Fire? If Yes, indicate the types and total amount of each for out-of-pocket-expense:
State other Household Plaintiffs' Names here if all Information on page is identical and applicable to them:

X. WRONGFUL DEATH
1. Are you asserting a claim for wrongful death? If yes, answer the questions below. Otherwise skip to Section XI.
2. Provide the name of the decedent.
3. Provide the date of birth for the decedent.

MonthDayYear
Date
4. Where did the decedent live at the time of the fire?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. What was the location of the decedent's death?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
6. What do you contend caused decedent's death?
7. Describe the relationship between the decedent and each Plaintiff asserting a claim for wrongful death:
8. Who lived in the same home with the decedent at the time of his/her death? For how long?
9. When is the last time any plaintiff lived with decedent prior to his/her death?
10. If the decedent was your spouse/registered domestic partner, were you ever legally separated from decedent, and if so, when?
11. What was decedent's job at the time of his/her death?
12. Did decedent smoke cigarettes during his/her life prior to death?
13. Identify any health conditions/diseases decedent suffered from at the time of his/her death that you contend were not a cause of decedent's death.
14. Identify all medications the decedent was taking at the time of his/her death.

XI. OTHER DAMAGES
1. Is any plaintiff identified in Section I claiming damages not specifically contemplated in any other section of the Damages Questionnaire? If Yes, answer Question 2. Otherwise skip to Section XII.
2. Briefly explain the nature of the claim (s) and requested compensation and provide supporting documents for each.

XII. MEDICAL INSURANCE INFORMATION
1. Do you or any family or household member included in Section 1 now have or did you or they previously have medical insurance that covers any injuries listed in Section VIII? If Yes, complete the questions below. Otherwise skip to Section XI.

3. If you or any Plaintiff identified in Section was entitled to receive medical items, services, and/or prescription drugs from any federal, state, or other governmental body, agency, department, plan, program, or entity that administers, funds, pays, contracts for, or provides medical items, services, and/or prescription drugs not previously listed above, provide the following information.

Name of Plan/Entity

Policyholder Name

Policy Number

Medical Condition Covered by Plan/Entity
4. If you or any Plaintiff identified in Section I has received medical treatment for any physical injury, emotional distress, or mental health issue included in Sections V or VI that was covered in full or in part by a Private Healthcare Insurance Plan or other form of payment, provide the following information for each such plan or entity. Include the complete full name of health plan.

Name of Plan/Entity

Policyholder Name

Policy Number

Medical Condition Covered by Plan/Entity
5. Have you or any Plaintiff identified in Section I lived in any state other than California since the Fire?

	Input Answer:
Claim Number:
Enrollment Start:
Enrollment End:
Branch:
Sponsor:
Treating Facility
Tribe:

XIII. OTHER INSURANCE INFORMATION
1. Did you submit an insurance claim for any property damage or business losses for which you are making a claim, on behalf of yourself or your business?
If Yes, provide the following information for each category of insurance coverage, attaching additional sheets if necessary. Otherwise skip to Section XIV.
2. Provide Insurance Information

Name of Insurance Carrier:

Insurance Policy Number:

Insurance Claim Number:
If multiple Loss Locations, submit for each location.

Name of Insurance Carrier:

Insurance Policy Number:

Insurance Claim Number:
If multiple Loss Locations, submit for each location.

Name of Insurance Carrier:

Insurance Policy Number:

Insurance Claim Number:

XIV. OTHER ASSISTANCE
1. Has any Plaintiff identified in Section I received a Small Business Association(SBA) loan or support from the Federal Emergency Management Agency (FEMA), Los Angeles County, or the State of California, or any non-profit organization or governmental agency worth over $1,000? If Yes, complete the following table indicating the type of support received. Otherwise, skip to Section XV.
Assistance Source:
Entity Providing Assistance:
Name of Recipient:
Amount Received:
Date Received:

MonthDayYear
Date
Purpose of Assistance:
Does Assistance Require Repayment
Has it Already Been Repaid
Date of Repayment or Date Repayment is Due

MonthDayYear
Date
2. Did you participate in any government-sponsored debris removal program for fire debris removal from your property?
If Yes, identify the program you participated in:

XIV. BANKRUPTCY
1. Has any Plaintiff identified in Section I been a debtor in a bankruptcy proceeding that (a) commenced on or after the date of the Fire or (b) commenced before but remained open on the date of the Fire?
Should be Empty:

Eaton Fire Litigation: Individual Plaintiff Damages Questionnaire

II. REAL PROPERTY DAMAGE

II. Real Property Damage continued.

II. Real Property Damage continued.

II. Real Property Damage continued.

II. Real Property Damage continued.

II. Real Property Damage continued.

III. PERSONAL PROPERTY CLAIMS

IV. OTHER PROPERTY DAMAGE

V. BUSINESS INCOME LOSS

VI. PERSONAL INCOME LOSS

VII. EMOTIONAL DISTRESS

VII. EMOTIONAL DISTRESS

VIII. PERSONAL INJURY

IX. ADDITIONAL LIVING EXPENSES

X. WRONGFUL DEATH

XI. OTHER DAMAGES

XII. MEDICAL INSURANCE INFORMATION

XIII. OTHER INSURANCE INFORMATION

XIV. OTHER ASSISTANCE

XIV. BANKRUPTCY