Business Name
Business Type
Degree of Damage
(Blank)
Affected
Minor
Major
Destroyed
Facility Owner or Renter
Street Address
City
ZIP Code
Business occupant
(Blank)
Owner
Leasee
Estimated Pre Disaster FMV of Bus.
Estimated Structure Loss
Est. $ Loss Furnishing / Inventory
Estimated economic activity loss
Cause of primary damage
Type of insurance
(Blank)
Structure and content
Contents (leasers)
Flood
Landslide
Earthquake
None
Civil Unrest Insurance or Rider?
Deductible
Amount of insurance for facility (if known)
Amount of insurance for contents (if known)
# of days closed due to disaster
Business Continuity Insurance?
(Blank)
Yes
No
Date Damage Occurred
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
:
AM
PM
Description of damages
Contact Name
Contact Phone
Contact Email
Location
Street
City
State
Zip