Personal Information (all fields are required):

      First Name:             Last Name:

      Address (where damage occurred):       

      Mailing Address (if different):

      City:              Zip:        (5-digit zip only)

      Do you own or rent the property where the damage occurred?   Owner Renter

Damage Information:

      Estimated Pre-Disaster Fair Market Value of the Structure: $(whole dollar amounts only)

      (if unsure of your property's value, click here to view the Assessor's assessed value.)

      Estimated Structure Loss in dollars:  $ (whole dollar amounts only)

      Estimated Personal Property Loss in dollars: $ (whole dollar amounts only)

      Primary Cause of Damage? Flood Rain Snow Wind Fire Landslide Earthquake       Date Damage Occurred: 

      Type of Insurance:  None Homeowners Homeowners & Flood Homeowners & Landslide Homeowners & Earthquake Renters

      Deductible Amount: $

       Is the property habitable?  Yes No     Accessible?  Yes No  

      Please choose a damage category (please check only one):

           Destroyed - Total Loss, Permanently Uninhabitable

           Major - Significant or Structural, >50% value, Uninhabitable

           Minor - Conditional use, repairable in under 30 days

           Affected - Living unit damaged, but still inhabitable.

      Description of damages:

      Contact Name         Phone

      Email: