Calcasieu Parish Police Jury : Form/Survey

Address of Damaged Property:

Owner's name:

Last Name

First Name

Middle Initial

Owner's mailing address:

Address

City

State

Zip

Owner's home/cell phone number:

Home Phone Number

Cell Phone Number

Owner's email address:

Email address

Resident's name (if different):

Last Name

First Name

Middle Initial

Resident's mailing address:

Address

City

State

Zip

Resident's home/cell phone number:

Home Phone Number

Cell Phone Number

Resident's email address:

Email address

What type of structure was damaged?

House

Travel trailer

Barn/shop

Manufactured home

Business

Other

If 'Other' selected, please describe:

Is anyone currently living in the structure?

Yes

No

Is this located inside city limits?*

Yes

No

What is the value of the structure (excluding land cost)?

What is the age of the damaged structure (in years)?

Is the structure insured?*

Yes

No

If yes, specify type of insurance:

Homeowners

Renters

Flood

What caused the damage?

Wind

Flood

Other

If 'Other' selected above, please describe:

If structure was flooded, please answer the following:

What was the approximate depth of the flood water?

Feet

Inches

How long was water in the structure?

Number of days

Number of hours

Additonal information or comments:

Can we contact you for additional details that may assist these efforts?

Yes

No

Please be advised that this information will be used for statistical purposes and to assist with planning for future events. The information provided may be shared with other government agencies, such as local municipalities and FEMA. This information will not be used for emergency assistance or rescue.

Name of individual submitting information:

Please press the submit button when complete.

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