Preliminary STORM Damage Assessment Form Name: * Address where damage occurred: * City, State, Zip: * Daytime Phone: * Email Address: Date of Incident: * Duration: * Structure Type: * Primary Residence Secondary Residence Commercial Property (No Structures) Did you own or rent the building? * Own Rent What is the damage report? * Do you have home owners insurance? * Yes No Will you be contacting you insurance company? * Yes No Are you out of power? Yes No Do you have any pictures of the damage? (all pictures can be emailed) * Yes No Do you have a private road that was damaged? * Yes No Do you have a well or septic/lagoon system that was damaged? * Yes No Was your furnace or water heated damaged? * Yes No Did any of your water lines brake or freeze? * Yes No If you are human, leave this field blank.