April 5th Earthquake Survey

Potential Applicant

First Name

Last Name

Phone

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Damage Location

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Damage Description

Damage Description- Describe damage to site, including approximate measurements where applicable. If work has been done or estimated, only include work to restore site to pre-disaster condition. Improvements & hazard mitigation are not included in the damage assessment phase.

Other Damages

None
Cosmetic damage (paint discoloration, siding, gutters, screens)
External damage (porch, carport, garage, outbuilding, retaining walls, landscaping, downed trees not affecting access to home)
Damage to mechanical components (furnace, boiler, water heater, HVAC, etc.)
Damage or disaster-related contamination to private well or septic system
Non-structural damage (roof, interior walls, exterior components, small vertical cracks in foundation, chimney)
Structural damage (partial/full failure of roof [rafters, joists, ridge boards, etc.], walls, framing or foundation [crumbling, bulging, collapsing or horizontal cracks > 2 inches])
Irreparable damage (only foundation remains, failure of 2 or more structural components [basement walls, foundation, walls, roof] or confirmed imminent danger)

Loss or damage estimate

Is property insured?

Have you contacted your insurance carrier?

Photos

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