Damage Collection Survey
Wayne County, IN EMA
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If business or non-profit, please enter the name below:
*
Type of structure:
*
Single Family Home
Mobile Home
Apartment
Condo
Business
Non-Profit
Is this your primary residence?
*
Yes
No
Own or Rent?
*
Own
Rent
If renting, please provide the owner's name and contact information:
Area affected:
*
Basement
1st Floor
Crawl Space
Business
Non-Profit
Additional Buildings
Please describe the damage sustained below:
*
For flood damage, please provide the depth of the water. If the basement is full of water and entered the first floor living area, type "FULL" and record the measurement of water on the first floor. If water only entered the basement, record the measurement of water.
Were any major mechanical/utility systems impacted? (Example: Furnace, water heater, well, etc.) Please list below:
*
Insurance
*
Homeowners
Flood
None
Renters
Sewer Backup
Photos of damages:
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