EMO - Damage Report Form

Do you require a callback?

Disaster:

Your First Name:

Your Last Name:

Your preferred language of written correspondence:

English French

Are you the owner?

Yes No, I rent or lease

Is there any other owner?

Yes No

Other owner information

First Name:

Last Name:

What type of property is this?

Residential Property Information

Choose one or more issue(s):

Loss or damage to residence

Loss or damage to personal property/contents

Residence was evacuated

Residence is not habitable

Erosion

Does anyone living in this household have a medical condition?

Yes No

What is the medical condition?

If you have been evacuated, are you :

Staying with friend or family? Red Cross Shelter?

Friend or family contact information

Contact name:

Contact phone number:

Red Cross Shelter Information

Shelter name:

Do you still have power at the property you are reporting?

Yes No

Commercial Property Information

What type of property is this?

Choose one or more issue(s):

Loss or damage to building

Loss or damage to inventory

Loss or damage to equipment

Business is not operable

Damage to land in production (Farm only)

Erosion

Property Information

Property Account Number
(PAN - found on your property tax bill):

Don't know your PAN? Look it up here.

Parcel Identifier Number
(PID - found on your property tax bill):

Address of damaged property

Postal Code:

Civic Number:

Civic Number Suffix:

Apartment Number / Suite:

Street Name:

Street Type:

Street Direction:

Community:

Province:

Is your mailing address different than the damaged property address?

Yes No

Mailing Address

Postal Code:

Civic Number:

Civic Number Suffix:

Apartment Number / Suite:

Street Name:

Street Type:

Street Direction:

Community:

Province:

Phone number that you can be reached at during the day:

Phone number that you can be reached at during the evening:

Cell phone number:

What is your email address?

When did this damage happen?

monthly calendar showing the dates from [Month] [Year]

What was the cause of this damage (description)?

Have you reported the losses and damages to your insurance company?

Yes No

Estimated damage amount

Additional Information

Measurement Unit:

Metric Imperial

What level was affected?

How deep was the water?

Basement

ft. in.

First floor

ft. in.

Other

ft. in.

Description of Other:

ELECTRONIC SIGNATURE

TYPING IN YOUR NAME AND ELECTRONICALLY SENDING THIS FORM CONSTITUTES YOUR ELECTRONIC SIGNATURE.

I accept

Signature

Date (yyyy/mm/dd)