Recovery Questionnaire * Required Fields *Name *Address *City *Municipality *State *Zip Code *Phone *Email *Preferred Contact Method PhoneEmail *Structure Type Single Family HomeApartmentManufactured HomeBusiness *Ownership OwnerRenter *Residency PrimarySecondaryRental UnitVacation Home *Did you experience water in your basement? YesNo *How much water (in inches) was in the basement? *Is your basement the first floor living space of your home? *Is your basement finished or unfinished? FinishedUnfinished *Do have living areas in your basement such as: finished bathroom, kitchen, living room, or bedroom(s)? YesNo *Any other damages experienced – please describe: *Is the structure still occupied? YesNo *Do you have Insurance? HomeownersRentersBothNone *Do you have Flood Insurance? YesNo *Do you have any private bridges or access roads damaged / destroyed? YesNo *Are any of your utilities out such as; gas, electricity, etc. YesNo *List your utilities that are out such as: gas, electricity, etc. If available, what are the estimated damage costs to your physical dwelling due to the event? How much is your insurance company covering? If available, what are the estimated damages costs to your land / property due to the event? How much is your insurance company covering? Total approximate value of ALL personal belongings within the entire home? Total approximate value of ONLY the damaged personal belonging within your home? Did you have damages to any of the following components of the home? Air Conditioning handler / unitHeating unit / furnaceHot water heaterOtherNone Heating Source: Home Heating OilNatural GasElectricityOther Hot water heater type? Natural GasElectricOilOther Please leave this field empty.
