Please enable JavaScript in your browser to complete this form.Full Name Enter First and Last Name State *IllinoisIllinoisCity *MorrisMorris County *Grundy CountyGrundy County Address *Enter Address Number and Street NameUnit / SuiteEnter Unit Apartment Number Phone *Email *Date of Event *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Enter Date of EventIncident Name Benton Street Battery Fire Type of Event *FloodNon-FloodType of Property *Single FamilyMulti FamilyCommercialIndustrialVacant LotField / Open LandMixed UnitOtherChoose OneOwn / Rent *OwnRentChoose OneInsurance Non Flood *NONEHomeownersRentersBusinessDo you have insurance? Choose one aboveAdditional Impacted Property *GarageShed / Out BuildingPool / SpaDebris on PropertyOtherChoose one aboveHabitable Status of Principle Structure *Habitable without RepairHabitable with Few RepairsUninhabitable Needs Extensive RepairsTotal Loss Unable to RepairChoose one aboveDo you have a Private Well? *YESNOChoose one aboveDid you Evacuate? *YESNOChoose one aboveDid you lose wages as a result of being displaced from your home? *YESNOChoose one aboveAre you a business in the evacuation area that was closed ? *YESNOChoose one aboveEstimated Lost Revenue ?Please put a Dollar Amount Did you experience power loss? *YESNOChoose one aboveDid you lose refrigerated food as a result of power loss? *YESNOChoose one aboveAdditional CommentsPlease add any additional information aboveFile Upload Click or drag files to this area to upload. You can upload up to 5 files. Please attach information here Submit