This comprehensive questionnaire is designed to assess the extent and nature of property damage. It is intended for use by insurance adjusters, property owners, or professionals involved in damage assessment. The goal is to gather detailed information to evaluate the damage, determine the cause, and estimate repair or replacement costs.
First Name
Last Name
Phone Number
Email Address
Mailing Address
City
State/Province
Postal/Zip Code
Property Address
City
State/Province
Postal/Zip Code
Type of Property
Residential
Commercial
Industrial
Agricultural
Age of Property
Size of Property (sq. ft./sq. m)
Type of Property
Owned
Rented
Leased
Insurance Company Name
Policy Number
Date of Policy Coverage
Name of Insurance Agent
Agent Phone Number
Agent Email Address
What happened? (e.g., fire, flood, storm, vandalism)
Were there any witnesses? If yes, provide names and contact information
What is the suspected cause of the damage?
Was the damage caused by natural disaster, accident, or human error?
Were there any contributing factors (e.g., poor maintenance, faulty equipment)?
Were emergency services contacted? (e.g., fire department, police)
Was the property secured after the incident?
Were any temporary repairs made?
List all areas of the property that were damaged | Extent of Damage (1=minor, 2=moderate, 3=severe) | Are there any safety hazards (e.g., structural instability, exposed wiring)? | ||
|---|---|---|---|---|
A | B | C | ||
1 | Roof | |||
2 | Walls | |||
3 | Flooring | |||
4 | Electrical Systems | |||
5 | Windows & Doors | |||
6 | Ceiling | |||
7 | Stairways & Railings |
List of damaged items | Description | Estimated Value ($) | ||
|---|---|---|---|---|
A | B | C | ||
1 | ||||
2 | ||||
3 | ||||
4 | ||||
5 |
Photo Description | Upload Photo | ||
|---|---|---|---|
A | B | ||
1 | | ||
2 | | ||
3 | | ||
4 | |
Video Description | Video Upload | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 |
Was there any pre-existing damage to the property?
If yes, describe the prior damage and provide documentation if available.
Have contractors or engineers inspected the property?
If yes, provide their names, contact information, and findings.
Have you received any repair estimates?
If yes, attach copies of the estimates.
File Description | Upload File | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 |
Is the property uninhabitable?
If yes, have you arranged for temporary housing or relocation?
Were official reports filed?
If yes, provide report numbers and copies if available.
Do you have any additional documentation related to the incident (e.g., maintenance records, receipts for repairs)? Please specify.
Is there anything else you would like to add about the incident or damage?
I authorize the release of any information related to this property damage assessment to my insurance company or authorized representatives.
To configure an element, select it on the form.