Primary Residence Damage Assessment FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Use this form to help Pacific County support our request for aid from Washington State and the Federal Government. This is the first step in being able to receive aid in our County. At this point, there is no guarantee that we will receive aid. If the damage occurred outside of Pacific County, please contact that county to report. Fill this form out one time for each location where damage occurred. Do not combine locations into one form.Name *FirstLastPhysical Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDo you rent or own this location? *--- Select Choice ---RentOwnCounty Assessed Structure Value *Estimated Structure Loss in Dollars* *Renters: Enter "0" and move to next question. Owners: Enter your best guess at what it will cost to repair the structure itself (carpet, walls, cupboards, furnace, doors, ductwork, etc. - all the parts that would generally stay with the house if you moved out, not including appliances.) You do not need to have official estimates, yet. This is a guess at this point. Do not wait for official estimates to complete this form.Estimated Personal Property Loss in Dollars* *These are things that you would take with you if you move (furniture, electronics, etc.) While generally not covered you may also report loss to vehicles here.Primary Cause of Damage* *Flood, Wind, Fire, Ect.Do you have insurance? Select all the apply*Home OwnersRentersNoFloodFireOtherInsuranceIf you have insurance, what is your deductible?If you have insurance, what is your deductible? insurance? all Organizations Is the location habitable?*?YesNoUnknownIs the location habitable?Is the location accessible?*YesNoUnknownIs the location Accessible?Category of Damage*Affected - CosmeticMinor - Minor RepairsMajor - Significant DamageDestroyed - Total LossAffected: The Residence has cosmetic damage only. Minor: The residence is damaged and requires minimal repairs to make habitable. Major: The residence has sustained significant damage and requires extensive repairs. Destroyed: The residence is a total loss.Description of DamagesBrief description of Damages (example: 3" of water. Damage to floors, walls. Loss of furniture, appliances, vehicles)Contact Name *Who is the best person to contract if additional information is needed (even if it's the same person as above)?Contact PhoneBest phone numberContact Email *When did the Damage occur?*When did the Damage occur?Do we have your permission to share your information with Volunteer Organizations providing local assistance?*?YesNoHave you completed the debris removal process?*YesNoStarted - Not CompleteThis is the first step and will help support Pacific County’s request for aid at the state and federal level. We do not know yet if we will receive any aid, but this helps support our request. In the meantime, do not delay clean up and repairs. Be sure to take pictures of your losses, including the water line with a point of reference, take video if it’s helpful, and keep all photos, videos, and receipts for potential future claims with state and federal agencies. If you also have additional damage to report for a business location, a rental property that you own, or a vacation home, please return to the main page and submit an additional form. For assistance with needs, call Pacific County Emergency Management (360) 875-9338Spam Security * = Submit
