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Steps
1.
Occupant Information
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2.
Contact Information
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3.
Location of Damage
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4.
Property & Damage Information
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Occupant Information
The purpose of this form is to collect information on physical damages to residential structures from emergencies and major disasters. Voluntarily submitting this information is not part of a claims process and does not guarantee reimbursement. Pierce County Department of Emergency Management will use this information to compile a preliminary assessment of all damages incurred throughout the county. You may be contacted at a later date if additional information is needed. You may print this form before pressing submit to keep for your personal records. For more information, contact the Pierce County Damage Assessment Call Center at 1 (866) 798-6363. NOTE: this number is only active after state government instructs Pierce County to collect this information, regardless, this form can be submitted at any time.
First Name
Last Name
Phone Number
Email
Occupant
Owner
Renter
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Contact Information
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First Name
Last Name
Phone Number
Email
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Location of Damage
Address 1
Address 2
City
State
Zip
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Property & Damage Information
Estimated Pre-Disaster Fair Market Value of Structure (FMV)
Estimated Structure Loss / Damage
Estimated Personal Property Loss / Damage
Primary Cause of Loss / Damage
-- Select One --
Flood
Snow
Rain
Wind
Fire
Landslide
Earthquake
Other
Type of Insurance
-- Select One --
Flood
Homeowners
Renters
Landslide
Earthquake
Other
Deductible
Category of Loss / Damage
-- Select One --
Affected
Minor
Major
Destroyed
Describe your loss and/or damages
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Optional: Upload a photo of the damage
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