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* indicates a required field

2. Basic Information

4. Date
   Date
6. Name*
7. Email Address*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*

17. Home Information

19. Property Type
    -- Select One --Single FamilyMulti-Family (Apt./Condo/Townhouse)Seasonal/VacationRentalBusinessOther
20. Occupancy Type
    -- Select One --Owner (Primary Residence)Owner (Seasonal Residence/Vacation Home)RentalNot applicable
22. Insurance type*

    Select all that apply.

    1. Flood Insurance (Structure Only)
    2. Flood Insurance (Contents Only)
    3. Flood Insurance (Structure and Contents)
    4. Homeowners Insurance
    5. Rental Insurance
    6. No Insurance
    7. Unknown
24. Foundation Type*
    -- Select One --SlabCrawl SpaceMichigan Basement (Dirt Floor)Partial BasementFull Basement, UnfinishedFull Basement, Finished
26. Residence is:*
    -- Select One --AccessibleInaccessible (cannot access residence because of flooded roads or debris inroad)

28. Damage Information

30. Home Type*
    -- Select One --Conventionally BuiltManufactured HomeOther (Specify)
31. Disaster Type*
    -- Select One --FloodingSevere Weather EarthquakeOther
33. What types of damage were caused by the disaster?*

    Check all that apply.

    1. Broken windows or doors
    2. Windows or doors are blown in
    3. Building is destroyed and only foundation remains
    4. Chimney collapse
    5. Damage to roof decking
    6. Gutter damage
    7. Loose or broken siding
    8. Major structural components are destroyed
    9. Minor roof damage
    10. Roof collapse failure
    11. Home has shifted from foundation
    12. Structure is in immediate danger from landslide, mudslide, sinkhole, etc.
    13. Two or more walls have been destroyed
    14. Walls are crumbling, bulging or collapsing
    15. Horizontal foundation cracks larger than 2 inches (new)
    16. Vertical foundation cracks (new)
    17. Black mold
    18. Damage to clothing and personal belongings
    19. Damage to drywall
    20. Damage to floor coverings
    21. Damage to insulation (torn, wet, damp, missing, etc.)
    22. Damage to refrigerator
    23. Damage to freezer
    24. Damage to washer and/or dryer
    25. Damage to furniture
    26. Water is in electrical outlets
    27. Other
35. Is additional assistance needed?*

    Check all that apply.

    1. Clean-up Kit (self-cleaning)
    2. Debris Removal (outdoor)
    3. Mold Remediation
    4. Food and Water
    5. Medical Equipment and/or Medication
    6. Muck-out (cleaning up flood damage to home)
    7. Water Removal
    8. Temporary Housing
    9. Utility Replacement
    10. Other
37. Additional Comments

39. Take a minimum of three photos:

    
    

41. Context*

    Site in relation to what is located around it

43. Curb *

    Close-up image with focus on the single site

45. Close-up*

    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).

47. Other

    Additional photos may be emailed to mannyd@cassco.org

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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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