* Information is required.
| * What date did this occur? |
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| * What is causing the flooding? |
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| * Where is the water coming from? |
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| * Please describe what happened. |
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| * Is this your primary residence? |
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| * Do you own or rent the residence? |
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| * Do you have flood insurance? |
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| * What rooms were affected by flooding? |
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| * What major appliances were damaged/destroyed in your home? |
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| * Did water cover any electrical outlets? |
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| * Select all public utilities that are NOT working at your home: |
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8
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| What is the water depth in inches in your basement? |
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| What is the water depth in inches in your first floor? |
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| Do you have any flood damaged interior building materials (i.e. carpet, drywall, etc.), if so please describe. |
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| Do you have any flood damaged home contents (i.e. hot water heater, furnace, etc.), if so please describe. |
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| Do you have any structural damage to your home (i.e. concrete wall collapse, roof collapse, etc.), if so please describe. |
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| * Did 40% or more of the contents inside your home get destroyed? |
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| * Are you able to stay in your home? |
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| If you are unable to stay in your home, do you have somewhere to go? |
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| * Are you in need of any urgent assistance? Choose from the following: |
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| * Are you in need any of the following assistance /resources? Choose from the following: |
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| If there is anything else you would like us to be aware of please list that here: |
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* Information is required.
If you send us a message, you will receive a Tracking Number allowing you to follow-up with your request, at your convenience.
