Damage Self Report

This form is for Initial Damage Reporting only. If there is an emergency, please dial 911.

This form is sent to the Collier County Emergency Management. THIS IS VOLUNTARY. Your participation helps us collect reports of damages so we have the ability to assess the highest impacted areas. This is not a form for local, state, or federal assistance.

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Location

Emergency event:

This report is for:

Damage Report Type is required

Address:

Address is required

Zipcode:

Five digit Zipcode is required

Description

Please describe the damage:

Add Images:

Upload Photos

Please enter the following information if this is your property:

Is this a business?

Yes

Don't Know / Not Applicable

If yes, enter the business name:

Are you the owner?

Owner

Renter

Do you have homeowner's insurance?

Yes

Don't Know / Not Applicable

Do you renter's insurance?

Yes

Don't Know / Not Applicable

Do you have flood insurance?

Yes

Don't Know / Not Applicable

Personal Impact

Have you been displaced from your residence due to the damage?

Yes

How many people live in your household?

Adults:

Children:

How long will your business be shut down:

How many employees do you have:

Contact Information

Please provide the following information about yourself:

Your First Name:

Your Last Name:

Your Phone Number:

Your Email: