Survivor Information Worksheet

Disaster Name:

Header: Contacts

First NameLast Name Spouse NameStreet NoStreet NameCityMailing AddressStateZipWork PhoneExtensionHome PhoneMobile PhoneFax Number
Other Contact InformationEmail AddressCheck to be on our email listSpouse Work PhoneExtension:Spouse Mobile PhoneSpouse Email AddressCan you volunteer in your area?Check to be on our mailing listInformation about the property effected by the disasterStreet NoStreet NameCityStateZipCheck if property is within the city limitsTax Assessor's Parcel Number (APN)New Owner Name (if sold since the disaster)Date of last saleStatus of property prior to disasterReferred By:Dwelling DamageYear BuiltSF of HouseInformation about the contractors hired after the disasterWill a contractor be hired?Contractor NameLicence NoLicence State:Date HiredContractor Rebuild EstimateRebuild TotalDate StartedDate EndedInformation about insurance which covers the propertyWas the property insured for the disaster?Insurance CompanyAgent NameBroker NameDate Insurance InitiatedDwelling Coverage AmountExtension PercentInsurance Company Scope/Repair AmountMSB Quick QuoteMSB Full QuoteThird Party Scope AmountThird Party Scope Contractorplace holder for supplimental insurance information (flood/eq etc)Information about the mortgage companyWas the property mortgaged prior to the disaster?Mortgage company nameDid you have an escrow account prior to the disaster?Have you given insurance proceeds to the insurance company which are being held in escrow?Information about legal representationHave you hired a lawyer due to the disaster?Law FirmLawyer NameBar NumberState of BarCourt Location:Date HiredDate Suit Filed:Date Settled:Reason for hiring lawyerPublic Adjuster InfoWas a public adjuster hired after the disaster?Public Adjuster NameLicense NoState of LicenseDate HiredDate FiredFee ChargedAmount Collected from Ins CoDate Permit ApplicationDate Permit IssuedDate of Cert OccupancyPermit Location:Permit InformationInformation about disaster relief organizationsDid you recieve help from FEMA?Please Describe:Did you recieve help from SBA?Please Describe:

Did you recieve help from any other organization?Please Describe:

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