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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 / Not Applicable
If yes, enter the business name:
Are you the owner?
Owner
Renter
Do you have homeowner's insurance?
Yes
No
Don't Know / Not Applicable
Do you renter's insurance?
Yes
No
Don't Know / Not Applicable
Do you have flood insurance?
Yes
No
Don't Know / Not Applicable
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:
Submit Request
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