Property & Owner Information: Parcel ID (STRAP): *Owner's Name: *Property Address: *City: *Your Phone#: *Your Email *Date of Damage: When did the damage occure? (mm/dd/yyyy -or- month/year)Estimate Overall Damage: (copy) NoYes1) Was building Uninhabitable or Condemned? (copy) (copy) NoYes2) Was building Leveled or Destroyed? Checkboxes NoYes3) Were you displaced from your home for 30 days or more? Damage Details: (Please provide details below if you had less severe damage or answered NO to questions 1 & 2 above) Shingle Loss? NoYesHoles in Roof? NoYes4) Roof Damage Shingle Loss? NoYesShutter Damage? NoYesHoles in Exterior Walls? NoYesHoles in Roof? (copy) (copy) NoYes5) Exterior Damage Stained Floors/Walls? NoYesMold/Mildew? NoYesCollapsed Interior Walls? NoYesCollapsed Ceiling? NoYesElectrical Damage? NoYes6) Interior Damage Any garage, shed, barn, (etc) damage? NoYes7) Garage and Outbuildings Repair Estimate: Any garage, shed, barn, (etc) damage? (copy) NoYes8) Are the repairs complete? (Estimated) Completion Date: (Estimated) Repair Cost Additional Comments: 9) Please provide additional details not covered above: Submit Form YES, I have checked the above information for accuracy:PhoneSubmit
