Forms • Waseca County, MN • CivicEngage

Name:*

Address*

City*

Phone Number*

Type of property*

Home

Business

Ownership*

Own

Rent

Rental Owners Name

Do you have insurance?*

Yes

No

Insurance company been notified?*

Yes

No

Date of damage*

Estimated amount of damage?

Type of damage*

	Fire
	Other

Flood (check all that apply)

	foundation cracking
	foundation bowing
	water seepage
	six or more inches of water in basement

	furnace or water heater damaged
	water on main level of home
	electrical outlets damaged

Hail (check all that apply)

	damage to siding or windows
	damage to roof or walls

damage to other buildings

Wind (check all that apply)

	damage to siding or windows
	damage to building structure (roof, walls, etc

damage to other buildings

Fire (check all that apply)

damage to walls or roof

damage to other buildings

Percent of Fire damage

Other (please explain)

Additional Information

* indicates required fields.