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* 1. Business Name

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* 2. Owners Name

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* 3. Street Address

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* 4. City

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* 5. Zip Code

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* 6. Business Occupant 

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* 7. Estimated Pre-Disaster Fair Market Value of Business

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* 8. Estimated Structure Loss in Dollars

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* 9. Estimated loss of Furnishings / Inventory

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* 10. Primary Cause of Damage

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* 11. Type of Insurance

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* 12. Deductible Amount (if applicable)

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* 13. Number of days closed due to disaster

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* 14. Business Continuity Insurance?

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* 15. Category of Damage

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* 16. Description of damage

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* 17. Contact Name

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* 18. Contact Phone Number

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* 19. Contact Email

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