1

Date of Incident

 *

Date of Incident

2

Type of Occurance

 *

Type of Occurance

Flood

High Winds

Severe Thunderstorm

Sewer Back-Up

Tornado

Other

3

Contact Information

 *

Contact Information

Name

Street Address

Municipality

State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Phone Numberext.

Email Address

4

Ownership

 *

Ownership

Rent

Own

5

Insurance

 *

Insurance

Deductible

Percent Covered

6

Damage Estimate (in dollars)

 *

Damage Estimate (in dollars)

7

Residence is habitable

Residence is habitable

Yes

No

8

Person living/sleeping in the basement

Person living/sleeping in the basement

Yes

No

9

Inches of water in the basement

Inches of water

10

Describe the Property Damage (water in basement, trees fell through roof, etc)

 *

Describe the Property Damage (water in basement, trees fell through roof, etc)

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