2. Please let us know if your home has suffered storm damage
   Please complete this form if your home has suffered damage as a result of Winter Storm Uri. This includes damage that occurred due to frozen/busted pipes.
   
   Please DO NOT use this form to request direct assistance or disaster relief. This form is not considered an insurance claim, you will have to report your damage to your insurance company. The City of Seabrook collects this information for disaster recovery purposes.
4. First Name*
5. Last Name*
7. Phone Number*
8. Email Address*
10. Physical Address that Incurred Damage*
12. Date Damage Occured*
    Date Damage Occured
13. Subdivision
15. Address1
17. City
18. State
19. Zip
21. Has your home been damaged as a result of the winter storm?*

    Please indicate yes if you have damage from frozen pipes which are now leaking.

    1. Yes
    2. No
23. Describe your home's damage*
25. What is the estimated cost of damage?*

    1. Less than $500
    2. $500 - $2,500
    3. $2,500 - $5,000
    4. $5,000 - $7,500
    5. $7,500 - $10,000

    1. $10,000 - $12,500
    2. $12,500 - $15,000
    3. $15,000 - $17,500
    4. $17,500 - $20,000
    5. More than $20,000
27. Do you have home insurance?*
    -- Select One --YesNo
28. Do you have flood insurance?*
    -- Select One --YesNo
30. Do you own or rent your home?
    -- Select One --OwnRent
31. If you have any photos of your damage please upload them here
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field