1.Address of damage

2.Contact information

Name

Company

Address

Address 2

City/Town

State/Province

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/Postal Code

Country

Email Address

Phone Number

3.Type of damage

Flood water

Wind damage

Other (please specify)

4.Provide a brief description of the damage.

5.Do you have home insurance and/or flood insurance? Select all that apply.

No insurance

Yes, home insurance

Yes, flood insurance

6.Do you rent or own?

Own

Rent (please provide landlord information)

7.How would you rate the level of damage?

Destroyed (Total loss, nothing repairable)

Major (Structural or significant damage requiring extensive repairs)

Minor (non-structural damage)

Affected (mostly cosmetic)

8.Do you have somewhere to stay, such as a friend or relative, if needed?

Yes

No