Individual Damage Report - For Primary Home Only
(Can be submitted by Homeowner or Municipal EMA Coordinator)
Date of Damage:
ex. 08-25-2004
Location of Damaged House
Physical Address (No P.O. Box) :
Municipality:
Owner of Damaged House
Name:
Address:
Phone:
E-mail
Value of the House
(do not include land value)
Estimated Value of house
Estimated Damage to house
House
or Mobile Home
(Only Check One)
Primary Residence
or Vacation Residence
(Only Check One)
Extent of House Damage
Destroyed
Major Damage
(Only Check One)
Minor Damage :
Affected
What was Damaged
(check all that apply)
Foundation
Floor (Frame) :
Exterior Walls :
Roof:
Interior Walls :
Plumbing:
Heating/AC:
Electrical
What Caused the Damage
(check all that apply)
Wind
Flood Water
Water in Basement
Water on 1st Floor
Fire
Fallen Tree
Other (Specify)
Homeowners Insurance Coverage
Full:
Partial:
None:
Flood Insurance Coverage
Full:
Partial:
None:
