Detailed Business Damage Estimate: Form to be sent to City Admin: See letter from Dan Wietecha

Business Detailed Damage Estimate

Section I. Business Information
Business Name Mailing Address City State Zip Code
Owner Name Municipality (Township, City, or Village) Owner Home Phone Business Phone
Section II. Disruption Informaiton
Is the business presently in operation?
_____YES

_____NO
_______ Number of days business has been
closed as a result of disaster.

_______ Number of days business anticipates to

remain closed.
Narrative Information on disruptions to business
Section III. Inventory/Property Losses
$ Estimated Uninsured Inventory/Property Loss Narrative Description
$ Estimated Insured Inventory/Property Loss Narrative Description
$ Unknown if insured Inventory/Property loss Narrative Description
SECTION IV. Property Owner/Landlord Information (IF DIFFERENT)
Name Mailing Address City State Zip Home Phone Work Phone
Section V. Building Damage
ESTIMATE $ AMOUNT INSURED?

TYPE OF DAMAGE “USE BEST GUESS” Yes No Unknown NARRATIVE DESCRIPTION OF DAMAGE

Structural Damage (exterior and interior)
Furnace/Air Conditioner
Water Heater
Sewer/Septic System
Water Utility/Well

Clean/Sanitize Expense
Replace Carpeting
Access to Business
(driveway/bridge, ramp, etc)

Other
Other
Other
Other