Please use this form to report residential damage that you have received from a disaster. PLEASE NOTE: This form is to be used to report damages to the Bethel Park Emergency Management Agency in order to estimate property damage in Bethel Park. This is not a claim form and no reimbursements or payments of any kind will be made based on this report.
Please do not use this form to submit damages from flooding--use the flood report form.
* Information is required.
| * Date Damage Occurred |
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| * Cause of Damage |
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11
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| * What type of structure is it? |
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| * Is this a primary or secondary residence? |
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| * Do you own the property or rent it? |
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| * How many people live in the home? |
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| Do you have insurance coverage for the damage? Select all insurance coverage that you have that may cover this damage. |
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14
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| * Select all types of damage that occurred: (Part 1) |
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10
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| * Select all types of damage that occurred: (Part 2) |
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12
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| * Select all types of damage that occurred: (Part 3) |
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9
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| * Select all types of damage that occurred: (Part 4) |
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7
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| * Did you lose 40% or more of the contents to your home? Vehicles are not considered contents of homes. |
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| * Select all of the damaged parts of your home: (Please ignore the numbers.) |
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10
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| * Please describe the damage to your home and what all contents were destroyed. |
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| * Are you able to stay in your home? |
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| If you are not able to stay in your home, do you have a place to go? |
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| * Are you in need of any urgent assistance? Choose from the following. |
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6
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| * Please select all public utilities that are NOT working at your home. |
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8
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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.
