Address of Affected Building

Please report any storm related damage to your home or business here. All information will be sent directly to the for review and tracking. This DOES NOT satisfy a report for insurance or immediate response purposes.

Address 1*

Address 2

City*

State*

Zipcode*

Location Type

This is a primary residence

* indicates a required field

Contact Information

I prefer not to include contact info

First Name

Last Name

Phone

Email

If contact address is same as affected building

Address 1

Address 2

City

State

Zipcode

Damage Assessment

Example damage levels

Affected (1)

Minor Damage (2)

Major Damage (3)

Destroyed (4)

Damage Level

Inches of Water

Has Insurance?

Estimated Cost of Damage

Do you have any documentation from a contractor or insurance to show estimation of damage?

Date of Incident

Notes

Estimated Cost

Confirmation

Please confirm information is correct before submitting