Village of Skokie Initial Damage Assessment for April 18, 2013 Flood

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* 1. Prefix - Please select one

Mr.

Mrs.

Ms.

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* 2. What is your first name?

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* 3. What is your last name?

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* 4. What is your address number?

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* 5. What is your street name?

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* 6. If applicable, what is your apartment/unit number?

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* 7. What is your telephone number?

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* 8. What is your email address?

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* 9. Which best describes the dwelling damaged in the April 18, 2013 flooding?

Single Family Home

Multi-Family Structure (Apartment Building, Duplex, two-flat, etc.)

Business

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* 10. Do you own or rent this dwelling?

Own

Rent

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* 11. What is the depth of water, in inches, experienced in the basement of this dwelling as a result of the April 18, 2013 flooding?

None

Minor Seepage

1" to 6"

6" to 12"

12" to 18"

18" to 24"

24" to 30"

30" to 36"

36" or more

n/a (no basement)

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* 12. What is the depth of water, in inches, experienced in the first floor of this dwelling as a result of the April 18, 2013 flooding?

None

1" to 6"

6" to 12"

12" to 18"

18" to 24"

24" to 30"

30" to 36"

36" or more

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* 13. Is the basement of this dwelling used as a living area?

Yes

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* 14. What type of insurance do you have?

Home Owners

Renters

Flood Insurance

Sewer Backup Insurance

None

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* 15. Is there obvious/visible structural damage to the dwelling?

Yes (see below)

If YES, please specify

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* 16. What type of installed flood control do you have in place at this location? Indicate all that apply.

Do Not Know

Overhead Sewer

Backwater Valve

Sump Pump(s)

Battery Backup for Sump Pumps

Installed Generator

Other (please specify)

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* 17. How much water collected in your street?

None

A Limited Amount

Curb to Curb

Over the Curb

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* 1. Prefix - Please select one

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* 2. What is your first name?

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* 3. What is your last name?

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* 4. What is your address number?

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* 5. What is your street name?

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* 6. If applicable, what is your apartment/unit number?

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* 7. What is your telephone number?

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* 8. What is your email address?

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* 9. Which best describes the dwelling damaged in the April 18, 2013 flooding?

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* 10. Do you own or rent this dwelling?

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* 11. What is the depth of water, in inches, experienced in the basement of this dwelling as a result of the April 18, 2013 flooding?

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* 12. What is the depth of water, in inches, experienced in the first floor of this dwelling as a result of the April 18, 2013 flooding?

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* 13. Is the basement of this dwelling used as a living area?

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* 14. What type of insurance do you have?

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* 15. Is there obvious/visible structural damage to the dwelling?

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* 16. What type of installed flood control do you have in place at this location? Indicate all that apply.

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* 17. How much water collected in your street?

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* 18. Please provide any other general comments not addressed by this survey.