Residential Detailed Damage Estimate---See post of City Administrator Dan Wietecha

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.