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Form Test
Form Test
Kitsap DEM
2023-03-09T08:58:08-08:00
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Occupant
*
Owner
Renter
First Name
*
Last Name
*
Phone Number
*
Email Address
*
Address 1
*
Address 2
City
*
State
*
Zip Code
*
Estimated Pre-Disaster Fair Market Value of Structure (FMV)
Estimated Structure Loss / Damage
Estimated Personal Property Loss / Damage
Primary Cause of Loss / Damage
Flood
Snow
Rain
Wind
Fire
Landslide
Earthquake
Other
Type of Insurance
Flood
Homeowners
Renters
Landslide
Earthquake
Other
Deductible
Category of Loss / Damage
Affected
Minor
Major
Destroyed
Describe your loss and/or damages
Optional: Upload a photo of the damage
Choose File
Submit
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