Preliminary FLOOD Damage Assessment Form Name: * Address where damage occurred: * City, State, Zip: * Daytime Phone: * Email Address: Date of Flood: * Duration: * Structure Type: * Primary Residence Secondary Residence Commercial Did you own or rent the building? * Own Rent Foundation Type * Basement Elevated Home Crawl Space Other Was your power usage or electric wiring damaged? * Yes No Did you have water inside the home? * Yes No Amount in inches: Did you have water in the basement? * Yes No Amount in inches? * Do you have damage to another structure on your propety? * Yes No Do you have a finished basement? * Yes No Do you have flood insurance? * Yes No Do you have a private road that was damaged? * Yes No Do you have a private/shared well or public water? * Public Water Private Well Do you have a septic/lagoon system or public sewer system? * Septic/Lagoon Public Sewer Where is your furnace located? * Main Floor Basement Garage Where is your water heater located? * Main Floor Basement Garage Did any of your lines brake or freeze? * Yes No If you are human, leave this field blank.