Residential Detailed Damage Estimate
Section I. Resident/Occupant Information
Last Name First Name M.I. Mailing Address City State Zip Code
Township, City, or Village of Residence Evening Phone Daytime Phone Check One
____ RENT ____ OWN
SECTION II. Property Owner/Landlord Information (IF DIFFERENT THAN OCCUPANT)
Name Mailing Address City State Zip Home Phone Work Phone
Section III. Habitability/Displacement Information
Habitiability Displacement Disposition
Is the residence habitable (safe and sanitary)?
_____YES (Skip this section)
_____NO (Complete this
section)
Key Criteria: SAFE AND SANITARY
Guidelines: Are conditions livable? Has disaster interrupted utility services such as water, sewer, power, heat/AC? Is the structure stable? Are there other circumstances that make it unsafe or unsanitary to continue living there?
_______ Number of occupants displaced
_______ Number of days occupants expect to
remain displaced
____ Staying with friends/relatives: Whom?___________________________
____ Staying in Public Shelter: Where?______________________________
____ Staying in hotel/motel: Name __________________________________
____ Relocated to/secured new temporary residence
____ Relocated to/secured new permanent residence
____ Still living in home that is not habitable (refer to human services agency)
____ Don’t have a place to stay (refer to human services agency)
____ Other: _____________________________________________________
REFERRED TO:
Temporary Street Address, City, State, Zip Temporary Phone Number
Section IV. Personal Property Losses
$ Estimated Uninsured Personal Property Loss Narrative Description
$ Estimated Insured Personal Property Loss Narrative Description
$ Unknown if insured personal property loss Narrative Description
Section V. Residential Damage
ESTIMATE $ AMOUNT INSURED?
TYPE OF DAMAGE “USE BEST GUESS” Yes No Unknown NARRATIVE DESCRIPTION OF DAMAGE
Structural Damage to Home (exterior and interior)
Furnace/Air Conditioner
Water Heater
Sewer/Septic System
Water Utility/Well
Clean/Sanitize Expense
Replace Carpeting
Access to Home
(driveway/bridge, ramp, etc)
Other
The damaged property is: (check one):
____ A primary/full-time residence; ____A Summer/Vacation Home or Cabin ____Other (explain:____________________)
PLEASE COMPLETE THIS FORM AS SOON AS POSSIBLE, AND DROP IT OFF AT CITY/VILLAGE HALL DURING NORMAL BUSINESS HOURS.
If you need more writing space, please staple or clip an additional sheet of paper to this form.
Thursday, August 23, 2007
Residential Detailed Damage Estimate---See post of City Administrator Dan Wietecha
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