* 1. What is your street address?

* 2. Contact Person's Name(s)

* 3. Flooding Impact & Frequency (Select as many as applicable)

* 4. Type of damage received

* 5. Estimated cost of damages 

* 6. Insurance % of damages insured

* 7. Health & Safety. Did flooding raise any health or safety hazards not covered by questions above? Describe:

* 8. Comments / Suggestions

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