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2. 
4. Contact and Property Information
6. Name*
7. Email Address*
9. Property Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Date of Incident (file a separate report for each incident)*
    Date of Incident (file a separate report for each incident)
18. Type of Property*

    1. Single-Family
    2. Duplex
    3. Multi-Family

    1. Business
    2. Other
19. If other, please describe
23. Description of Damages and Documentation
25. Water Levels

    Please report the level of water (in feet) associated with this incident.

27. Basement
28. 1st Floor
29. 2nd Floor
31. Other
32. If other, please describe
34. Describe Damages to Foundation (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
36. Describe Damages to Exterior Walls (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
38. Describe Damages to Interior Walls (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
40. Describe Damages to Flooring (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
42. Describe Damages to Windows and Doors (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
44. Describe Damages to Fixture (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
46. Describe Damages to Furnace (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
48. Describe Damages to Water Heater (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
50. Describe Damages to Utilities (select all that apply)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
52. Describe Other Damages (select all that apply and name feature below)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
54. Name of Feature Damaged (as reported above)
56. Describe Other Damages (select all that apply and name feature below)

    1. Repairs Required
    2. Damaged But Usable

    1. Wet/Damp
    2. Dry

    1. Photos and/or Documentation Attached
58. Name of Feature Damaged (as reported above)
60. Additional Comments
62. Documentation

    Upload supporting photos and/or documentation. File types accepted include .jpg, .png, .pdf, .docx, .xlsx, .mp4, and .zip files.  If you have more than four files, please call (269) 329-4422.

64. File Upload #1
65. File Upload #2
66. File Upload #3
67. File Upload #4
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69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

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