Disaster Caused Losses Reporting Form

Disaster Caused Losses Report Form

Thank You for reporting your damage to the Cass County Emergency Management Agency.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Disaster

MonthDayYear
Date
Describe Disaster Caused Losses. Example: Structural Damage, Basement Flooding, Water intrusion into living space, Damage to HVAC or other equipment, Etc.
Do you have insurance?
Do you have flood insurance?
Any other information you would like to share
Disclaimer: this information will be shared with the cass county emergency management agency, American Red Cross and Indiana department of homeland security for the purpose of seeking disaster assistance for the people and governments of cass county
Should be Empty:

Disaster Caused Losses Report Form