Pre Disaster Assessment survey

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1. Please provide the following contact information:

Please provide the following contact information:   Name:
Address:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP:
Email Address:
Phone Number:

2. Is this property occupied by:

Is this property occupied by:   Owner Renter

3. Is this propery accessible for inspection at a later date?

Is this propery accessible for inspection at a later date?   Yes No

4. Are you still able to live in the home?

Are you still able to live in the home?   Yes No

5. Is this property a:

Is this property a:   Single Family home Multi-Family home Mobile home

6. What type of insurance do you have for this property?

What type of insurance do you have for this property?   Structure and Contents Contents Flood None

7. What is the deductible on the policy?

What is the deductible on the policy?

8. Have you contacted your insurance company and also documented the damage for your own records (ie photos, videotape)?

Have you contacted your insurance company and also documented the damage for your own records (ie photos, videotape)?   Yes No Unsure

9. please describe the damage to your property

please describe the damage to your property