Disaster Relief Assistance Request

Assistance for businesses affected by natural disasters

Disaster Relief

Name

Company

Address where damage occured

Website

Phone

Number of employees displaced/lost work

Home-based business?

Yes No

Number of employees threatened

Insurance carrier

Insurance agent

Insurance carrier/agent phone number

Policy number

Type of policy (flood/hazard/business owner policy/other)

Limit $

Business income/business interruption

Yes No

Building owned

Yes No

Year built

Limit of liability $

Content insured value $

Content actual cash value $

Estimated economic loss (loss in sales) $

Physical damage to business $

Immediate needs of business (space, financing, marketing, etc)

How can we best help you with your insurance questions and issues?