Damaged or Destroyed Property

First Name *

Last Name *

Damaged Property Address *

City or Township *
Albert LeaAldenClarks GroveCongerEmmonsFreebornGenevaGlenvilleHartlandHaywardHollandaleManchesterMyrtleTwin Lakes

Mailing Address

If different from damaged property address.

Daytime Phone Number *

555-555-5555

Evening Phone Number *

555-555-5555

Email Address *

Date of Damage *

Type of Damage Being Reported *
Flood DamageStorm (wind, hail, etc) DamageOther Damage

Select ANY that apply to your property's damage. *
Foundation damageWater seepage in basementZero to five inches of water in basementSix or more inches of water in basementWater on main level of homeFurnace or water heater damagedElectrical/outlets damagedStorm damage to exteriorSewer back-upOther damage

Briefly Describe Damage to Property

Please leave this field empty.

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