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* 1. First Name

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* 2. Last 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. Own or Rent?

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* 7. Estimated Pre-Disaster Fair Market Value of Structure (Estimate a number.  Do not say I don't know or leave blank.)

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* 8. Estimated Structure Loss in Dollars (Estimate a number.  Do not say I don't know or leave blank.)

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* 9. Estimated PERSONAL PROPERTY Loss in Dollars (Estimate a number.  Do not say I don't know or leave blank.)

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* 11. Type of Insurance

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* 12. Deductible Amount (if applicable)

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* 13. Habitable?

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* 14. Accessible?

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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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* 20. Please indicate if you would like your contact information shared with disaster assistance teams or volunteers who are in the area to assist citizens with cleanup.

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