Please fill out this form if you have water damage or flooding from the storm on June 25 - 26, 2021.
The purpose of this form is to collect information only for reporting to the State pursuant to Public Act 390 of 1976 and is not mechanism for any other type of reimbursement or financial assistance.

This is not a damage claim form pursuant to Public Act 222 of 2001.

All information provided in this form is subject to Freedom of Information Act requests subject to State law.

Personal Information

Name:*

Address:*

Phone Number:*

Email:

Number of People in House (Adults/Children):

Damage Information

Do you have water damage?*

Yes

No

What type of structure received damage?
(Check all that apply)*

Single Family Home Vacation Home / Cottage Manufactured Home Apartment / Rental Unit

Business Public Facility Non-Profit Organization

What level of floor was affected?
(Check all that apply)*

Crawl Space Basement First Floor

Second Floor Any Other Floor

If there was damage to livable space within the building, what percentage of the space is unlivable?*

20% 40% 60%

80% 100%

If the basement had water damage, does the basement include livable space?
(Examples: bedroom, finished basement, etc.)*

Yes

No

What is the overall level of damage within the building?*

Affected - minimal damage, mostly cosmetic with less than 3 inches of water Minor Damage - under 50% of area damaged with 3 to 18 inches of water

Major Damage - over 50% of area damaged with over 18 inches of water Destroyed - 100% of repair costs exceed the value of the structure

Please provide a brief description of your loss.*

Insurance Information

Do you have insurance coverage for the structure?*

Yes

No

Does your insurance cover the loss?*

Yes

No

Insurance Coverage (If yes, please provide the name of your carrier):

What amount of the loss is covered by your insurance, if applicable?*

In Full Partially

Not at All

What is the total estimated value of your loss?*

Explanation/ Additional Comments:

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The deadline for Flood Damage paperwork is Thursday, July 1, 2021.
You can now fill out the paperwork online at www.cityofinkster.com and also come into City Hall or DPS office at 26900 Princeton.
You must submit copies of your pictures. If you have any questions, please call DPS office at 313-563-9774.