EMO - Damage Report Form

Residents in New Brunswick are advised to report damages caused by the Hurricane Dorian on September 8, 2019

To apply for Disaster Financial Assistance (DFA) for Hurricane Dorian which happened on September 8, 2019, homeowners, small business and not-for-profit organization are asked to register their damage to Service New Brunswick.

Once registered a DFA package will be mailed out to you. Enter the required information below and click "Submit".

* Required fields

Do you require a call back?

Yes

*	First Name:
*	Last Name:
*	Do you	Own Rent or Lease
*	If yes, is there any other owners?	Yes No
	If yes, what is their name?
	First Name:
	Last Name:

*	What type of property is this:	Residential
		Cottage
		Apartment
		Small business
		Retaining wall

*	Disaster:
	Parcel Identifier Number (PID - found on your property tax bill):
	Property Account Number (PAN - found on your property tax bill):
	Address of damaged property:
Please enter Postal Code and search for Address
*	Postal Code: ([Postal Code Trouble?])
*	Is there a phone number that you can be reached during the day:	() -
*	Is there a phone number that you can be reached during the evening:	() -
	Do you have a cell phone number?	() -
	What is your email address?
*	When did this damage happen? Date:

*	What was the cause of this damage (description):


*	Language of written correspondence	English French


	Residential Property (check one or more):	Loss or damage to residence
		Loss or damage to personal property/contents
		Residence was evacuated
		Residence is not habitable
		Erosion


*	Do you need to be evacuated from your home?	Yes No
		If YES, call 9-1-1.

*	Do you still have power at the property you are reporting?	Yes No
		If No, was it turned off by:
		Qualified Electrician or NB Power

*	If you have been evacuated are you	Staying with friend or family?
	Name:
	Telephone Number:	() -
		Red Cross Shelter?
	Shelter Name:
		N/A

*	Does anyone living in this household have a medical condition?	Yes No Prefer not to answer
	If yes, what?

	Commercial Properties (check one):	Farm
		Small business
		Non-profit organization

	Commercial Properties (check one or more):	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


*	Have you reported the losses and damages to your insurance company?	Yes No

	What is the estimated dollar amount of damage:

	Additional Information if a flood

	Units of Measure

	How deep was the water?

	What level?
	Basement
	First floor
	Other
	Description of "Other":

*	Was there sewer back-up?	Yes No

	Please answer the following questions: Do you have any electrical or structural issues? How did you heat your home, by propane or barbecue? And did you have your generator inside? Do you have any comments and additional information?


*	Date: