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2. Homeowner's Name*
3. Today's Date*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address
14. Is your home habitable?*

    1. Yes
    2. No
15. Are you living in the home now?*

    1. Yes
    2. No
16. Did your home receive structural damage? (i.e. foundation)*

    1. Yes
    2. No
18. Describe the structural damage, if any:
20. Did your furnace, water heater, electrical panel, or appliances get damaged?*

    1. Yes
    2. No
21. If yes, describe the damage.
23. Is there water in your basement/crawl space right now? *

    1. Yes
    2. No
24. If yes, how much
26. Is your basement finished?*

    1. Yes
    2. No
27. If your basement/crawl space was damaged, describe the damage.
29. Did your home receive damage to the first floor?*

    1. Yes
    2. No
30. If yes, how much?
32. Has anything been done to remove damaged materials?*

    1. Yes
    2. No
33. If yes, please explain further.
35. If you have started to clean up the damage, who performed the work?
37. Have all curbside debris been picked up?*

    1. Yes
    2. No
38. Will you have more curbside debris to be picked up?*

    1. Yes
    2. No
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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