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2. 
3. Please fill out this form if you have water damage or flooding from the storm on June 25 - 26, 2021.

   The purpose of this form is to collect information only for reporting to the State pursuant to Public Act 390 of 1976 and is not mechanism for any other type of reimbursement or financial assistance. 

   This is not a damage claim form pursuant to Public Act 222 of 2001.

   All information provided in this form is subject to Freedom of Information Act requests subject to State law.

5. Personal Information
7. Name*
9. Address*
11. City*
12. State*
13. Zip Code*
15. Best Contact Phone Number
16. Best Contact Email Address
18. Damage Information
20. Do you have water damage?*

    1. Yes
    2. No
21. What type of structure received damage?*

    Check all that apply

    1. Single Family Home
    2. Vacation Home / Cottage
    3. Manufactured Home
    4. Apartment / Rental Unit

    1. Business
    2. Public Facility
    3. Non-Profit Organization
23. What level of floor was affected?*

    Check all that apply

    1. Crawl Space
    2. Basement
    3. First Floor

    1. Second Floor
    2. Any Other Floor
24. If the basement had water damage, does the basement include livable space?*

    Examples:  bedroom, finished basement, etc.

    1. Yes
    2. No
26. If there was damage to livable space within the building, what percentage of the space is unlivable?*

    1. 20%
    2. 40%
    3. 60%
    4. 80%
    5. 100%
27. What is the overall level of damage within the building?*

    1. Affected - minimal damage, mostly cosmetic with less than 3 inches of water
    2. Minor Damage - under 50% of area damaged with 3 to 18 inches of water
    3. Major Damage - over 50% of area damaged with over 18 inches of water
    4. Destroyed - 100% of repair costs exceed the value of the structure
29. Please provide a brief description of your loss.*
31. Insurance Information
33. Do you have insurance coverage for the structure?*

    1. Yes
    2. No
34. Does your insurance cover the loss?*

    1. Yes
    2. No
36. What amount of the loss is covered by your insurance, if applicable?*

    1. In Full
    2. Partially
    3. Not at All
37. What is the total estimated value of your loss?*
41. Please submit this form by Friday July 2nd, 2021.

    The form can be submitted by:

    • Selecting Submit on this electronic form.
    • Email the completed form to stormdamage@cityofwestland.com
    • Drop off the form at Westland City Hall located at 36300 Warren Rd, Westland MI, 48185

    
    

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43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field