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Self-Reporting Damage Assessment

  1. Basic Information

  2. Home Information

  3. Insurance type*

    Select all that apply.

  4. Damage Information

  5. What types of damage were caused by the disaster?*

    Check all that apply.

  6. Is additional assistance needed?*

    Check all that apply.

  7. Take a minimum of three photos:

  8. Site in relation to what is located around it

  9. Close-up image with focus on the single site

  10. Emphasize the damage (visible water lines from receded flood waters are very helpful; it is also important to capture structural damage like walls that are collapsed or buckling for floors and roofs).

  11. Additional photos may be emailed to

  12. Leave This Blank:

  13. This field is not part of the form submission.