Name: 

Address:  

Block/Lot (if known)
Block:   Lot:  

Phone:  

E-MAIL:   

Are you in a FEMA designated Flood Plain? Yes No

Do you have flood insurance? Yes  No

Within the last ten (10) years, how many times have you experienced flooding on your property?:

1-2  3-4 5-6 7-8 9-10 11+

Where do you believe the waters originated? (Check all that apply):

Stream, Brook, Pond, etc.
Clogged/Inoperable Catch Basin
Run-Off from an Adjacent Property
Roadway Run-Off
Groundwater entering through the floor

Did you experience a sanitary sewer back-up as a result of the flooding? This could be back-ups from your toilets, sinks and/or washing machine.

Yes No

Did you experience flooding in your… (Check all that apply)

Street Yard Driveway Garage Basement Other:

For each item checked above, briefly describe how and where the water entered and the extent of the  damage experienced.

THANK YOU VERY MUCH FOR PROVIDING THIS INFORMATION

Please click Submit to complete the survey.