Impact Survey | Grundy County

Full Name

Enter First and Last Name

State *

City *

County *

Address *

Enter Address Number and Street Name

Unit / Suite

Enter Unit Apartment Number

Phone *

Email *

Date of Event *

Enter Date of Event

Incident Name

Type of Event *

Flood
Non-Flood

Type of Property *

Choose One

Own / Rent *

Own
Rent

Choose One

Insurance Non Flood *

NONE
Homeowners
Renters
Business

Do you have insurance? Choose one above

Additional Impacted Property *

Choose one above

Habitable Status of Principle Structure *

Habitable without Repair
Habitable with Few Repairs
Uninhabitable Needs Extensive Repairs
Total Loss Unable to Repair

Choose one above

Do you have a Private Well? *

YES
NO

Choose one above

Did you Evacuate? *

YES
NO

Choose one above

Did you lose wages as a result of being displaced from your home? *

YES
NO

Choose one above

Are you a business in the evacuation area that was closed ? *

YES
NO

Choose one above

Estimated Lost Revenue ?

Please put a Dollar Amount

Did you experience power loss? *

YES
NO

Choose one above

Did you lose refrigerated food as a result of power loss? *

YES
NO

Choose one above

Additional Comments

Please add any additional information above

File Upload

Click or drag files to this area to upload. You can upload up to 5 files.

Please attach information here