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4-1-23 Storm Damage Assessment
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Date of Assessment
MM
/
DD
/
YYYY
Submitted By: (Full Name)
Your answer
Address (Road)
Your answer
City/Village/Township
Your answer
Status
Owner
Renter
Clear selection
Property Owner Name (Full Name)
Your answer
If renter, Renter Name (Full Name)
Your answer
Contact Phone Number(s) for Above
Your answer
Residence
Primary
Secondary
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Category
Single Family
Mobile Home
Apartment
Condo
Business or Industry
Road
Bridge
Other:
Clear selection
Insurance Type(s)
Flood
Homeowner's
Renter's
Sewer B/U Rider
Other:
Type of Damage
Flood / Water
Wind
Fire
Explosion
Tornado
Hail
Tree Down
Ice Storm
Other:
Items Damaged
Home
Business
Vehicle
Water in...
Crawl Space
Basement
1st Floor
Water Depth in Crawl Space
Your answer
Water Depth in Basement
Your answer
Water Depth in 1st Floor
Your answer
Water Depth in Other Area (include area)
Your answer
Type(s) of Damage Outside
Roof (Shingles Only)
Roof (Plywood)
Roof (Trusses)
Siding
Walls
Windows
Foundation
Other:
If window damage, how many windows?
Your answer
Garage?
Attached Garage
Detached Garage
Shed
None
Other:
Type(s) of Damage Inside
Ceiling
Walls
Flooring
Joist Ceiling/Floor
Basement
Foundation
Other:
Road Status:
Open
Closed
Other:
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Roadway Obstruction(s)
Power Pole and/or Lines
Trees / Limbs
Flooding
Washout or Hole
Other:
Preliminary Level of Damage
Affected
Minor
Major
Destroyed
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Verified (1st)
Your answer
Verified (2nd)
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Injuries? (quantity)
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Fatalities? (quantity)
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Other incidents? (quantity and description)
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Photos taken?
Yes
No
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How Many Photos?
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Location and Direction of Photos
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Additional Comments
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Report Taken By
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Date Confirmation
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