This questionnaire is designed to gather comprehensive information about property damage. Please answer all questions as accurately and completely as possible. Incomplete or inaccurate information may delay the assessment process. If a question is not applicable, please indicate "N/A." If you are unsure of an answer, please provide your best estimate and mark it as an estimate.
Date of Assessment
First Name
Last Name
Phone Number
Email Address
First Name
Last Name
Phone Number
Email Address
Street Address
City
State/Province
Postal/Zip Code
Type of Property
Residential
Commercial
Industrial
Agricultural
Date of Incident/Damage Occurrence
Time of Incident/Damage Occurrence
Cause of Damage
Fire
Flood
Storm
Earthquake
Vandalism
Vehicle Impact
Other:
Description of Incident/Damage: (Provide a brief narrative of what happened)
Type of Foundation: (e.g., Slab, Basement, Crawl Space)
Description of Damage: (e.g., Cracks, Settling, Water Damage)
Estimated Extent of Damage
Minor
Moderate
Severe
Type of Foundation: (e.g., Slab, Basement, Crawl Space)
Interior Wall Material: (e.g., Drywall, Plaster)
Description of Damage: (e.g., Cracks, Holes, Water Damage, Fire Damage)
Estimated Extent of Damage
Minor
Moderate
Severe
Type of Roof: (e.g., Shingle, Tile, Metal)
Description of Damage: (e.g., Missing Shingles, Leaks, Structural Damage)
Estimated Extent of Damage
Minor
Moderate
Severe
Number of Damaged Windows
Number of Damaged Doors
Description of Damage: (e.g., Broken Glass, Damaged Frames)
Estimated Extent of Damage
Minor
Moderate
Severe
Type of Flooring: (e.g., Carpet, Hardwood, Tile)
Description of Damage: (e.g., Water Damage, Staining, Cracks)
Estimated Extent of Damage
Minor
Moderate
Severe
Description of Damage: (e.g., Water Damage, Cracks, Holes)
Estimated Extent of Damage
Minor
Moderate
Severe
Description of Damage: (e.g., Water Damage, Cracks, Holes)
Estimated Extent of Damage
Minor
Moderate
Severe
List Major Damaged Items | Description of Damage to Personal Property: (e.g., Water Damage, Fire Damage, Broken) | Estimated Value of Damaged ($) | ||
|---|---|---|---|---|
A | B | C | ||
1 | Furniture | |||
2 | Appliances | |||
3 | Electronics | |||
4 | Artwork | |||
5 | Garage Items | |||
6 | Instruments | |||
7 | Vehicles | |||
8 | Boat |
Description of Damage
Estimated Extent of Damage
Minor
Moderate
Severe
Description of Damage
Estimated Extent of Damage
Minor
Moderate
Severe
Description of Damage: (e.g., Damaged Trees, Plants, Lawn)
Estimated Extent of Damage
Minor
Moderate
Severe
Description of Damage
Estimated Extent of Damage
Minor
Moderate
Severe
Description | Upload Photo | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Description | Upload Photo | ||
|---|---|---|---|
A | B | ||
1 | |||
2 | |||
3 | |||
4 | |||
5 |
Insurance Company Name
Policy Number
Claim Number
Is the property currently habitable?
Are there any safety concerns related to the damage?
If yes, please explain.
Has any mitigation work been performed?
If yes, please explain.
Other relevant information: (e.g., Access restrictions, Contact information for other parties involved)
I certify that the information provided in this questionnaire is true and accurate to the best of my knowledge.
Signature of Assessor
Signature of Property Owner
To configure an element, select it on the form.