Name *

First Name

Last Name

Phone *

(###)

###

####

Alternate Phone

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you the owner of the business? *

Yes

No

Are you a non-profit? *

Yes

No

Do you own or lease your location? *

Own

Lease

Are you a farm? *

Yes

No

Do you have a COVID EIDL (Economic Injury Disaster Loan)? *

Yes

No

Did you receive an EIDL (Economic Injury Disaster Loan) after Tropical Storm Irene? *

Yes and my loan has been paid off

Yes and I still have a monthly payment

No

Is your business open? *

Yes

No

Check the kind(s) of damage you have sustained: *

Exterior

Interior

No damage, the surrounding area and roads are closed

Other (explain below)

Have you reported your damage to 211? *

Yes

No

Do you have flood insurance? *

Yes

No

Do you have other types of business interruption and/or continuity insurance? *

Yes

No

Check the steps you have taken below: *

Taken pictures

Begun to document impact of flooding

Called you insurance agent

Other (explain below)

Check the type(s) of assistance you are seeking: *

Managing next steps

Financial management

Individual advising

Other (explain below)