Damage Report

Damage information (private property, business losses, and public infrastructure damages) must be first collected by local emergency management officials. Based upon the information collected by local officials, Illinois may request a Federal/State Preliminary Damage Assessment (PDA). Please ensure your submission is as complete and accurate as possible. Thank you in advance for your submission!

Damage Type *Please Select OneNon-Flood RelatedFlood Related

Approximate Date / Time of Occurance

Date

Time

Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Structure Type *Please Select OneSingle FamilyMulti-FamilyBusinessMobile Home

Own/Rent *Please Select OneOwnRent

Habitable Status *Please Select OneHabitable Without RepairsHabitable With Few RepairsUninhabitable Needs Extensive RepairsTotal Loss – Unable to Repair

Insurance Coverage Status *Please Select OneNoneHome OwnersCommercial BusinessFloodSewerRenter

Insurance Provider

Name *

First

Last

E-Mail Address *

Phone *

Comment or Additional Information

File/Photo Upload

Click or drag files to this area to upload. You can upload up to 10 files.

Please upload photos of your damage.

Submit