June 2018 Flood Assessment

First Name

Last Name

Email Address

Address

Address Line 2

City

State

Zip Code

Country

Water Level in Structure (Approx. Feet)

Percentage Damage:

Building Type:

Primary Home Secondary Home Business Isolated No Entry

Status

Own Rent No Entry

Home Owner's Insurance

Yes No No Entry

Estimated Income

High 30K + Medium 10-30K Low 1-10K No Entry

Do you participate in the National Flood Program

Yes No No Entry

Property Value

Estimated Loss