If your home or business was damaged by flood waters, complete the following form. 1. Address: 2. Cross streets: 3. City or Township: 4. Owner: 5. Phone number: 6. Enter the letter of the damaged structure type: A. Residential B. Mobile/manufactured home C. Condo D. Apartment E. Commercial F. Residential G. Out building H. Other 7. Water level inside structure, in inches or feet, if known: 8. Water level by structure level (Basement, First Floor, Second Floor, etc): 9. If basement, finished or unfinished: 9. Enter the letter of the appropriate damage level category: A. Minimal damage, less than 3" water in any room B. Less than 50% damage, 3-18" water in any room C. Greater than 50% damage, over 18" water in any room D. Permanently uninhabitable, 100% damage 10. Enter the letter(s) of the appropriate type of insurance coverage: A. None B. Homeowners C. Flood D. Water backup / damage rider E. Unknown 11. Enter the letter of the appropriate damage amount in dollars: A. $0-$10,000 B. $10,000-$50,000 C. Over $50,000 12. Description of damage: 13. If you have photos, attach minimal photos that show the damage.