Flood Damage Survey

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* 1. Address

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Is your home your primary residence

Yes

No

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* 3. Amount (in inches) of water in the residence

Waterline at 1 to 3 inches in living space

Waterline exceeds 3 inches but is below 18 inches

Waterline exceeds 18 inches (electrical outlets in living space)

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* 4. Do you have homeowner's/renter's insurance?

Yes

No

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* 5. Do you have flood insurance

Yes

No

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* 6. Please share any other comments you have below: