Initial Report:             Supplemental Report:                                     Date:

1.  Jurisdiction(s) Affected:

2.  Disaster: Type      Date     Time

3.  Report by: Name *     Title

Email

4.  Affected Individuals: (Assign affected individuals to only one category.)

               a. Fatalities                           d. Missing

               b. Injuries                             e. Evacuated

               c. Hospitalized                       f. Sheltered

5. Property Damage:

               a.Residence:

                                  # Destroyed        #Major           #Minor          #Inaccessible      # Insured

              Single Family                       

              Multi Family                         

          Mobile Homes                         

                  Estimated Losses to Residence $

               b.Business:

                                  # Destroyed        #Major           #Minor             # Insured

                   Estimated Loss to Business $

               c.Public Facilities:

                 Type of Work or Facility        Estimate $       # of Sites          Brief Description of Damages
                           Categories

                     A. Debris Removal                          

                     B. Protective Measures                   

                     C. Roads & Bridges                         

                     D. Water Control                             

                     E. Buildings Equipment                   

                     F. Utilities                                        

                    G. Parks and Recreations                

                        TOTAL ESTIMATE $

    *  These fields are required.