Initial Damage Reporting Form
This form is for Initial Damage Reporting only.
If there is an emergency, please dial 911.
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Location
Emergency event:
This report is for:
-- SELECT A REPORT TYPE --
Debris Clearance
Residential Damage
Commercial/Industrial Damage
Public Facility Damage
Agricultural Damage (crops, ag buildings, equipment)
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
No
Don't Know
If yes, enter the business name:
Are you the owner?
Owner
Renter
Do you have homeowner's insurance?
Yes
No
Don't Know
Do you renter's insurance?
Yes
No
Don't Know
Do you have flood insurance?
Yes
No
Don't Know
Personal Impact
Have you been displaced from your residence due to the damage?
Yes
No
How many people live in your household?
Adults:
0
1
2
3
4
5
6
7
8
9
10
11
12
More than 12
Children:
0
1
2
3
4
5
6
7
8
9
10
11
12
More than 12
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:
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