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Dwelling Flood Field Questionnaire

This click-through questionnaire collects the information commonly needed for a residential dwelling flood claim. Complete what you know, sign at the end, then print or save as a signed PDF.

Step 1

Before You Start

This click-through questionnaire collects the information commonly needed for a residential dwelling flood claim. Complete what you know, sign at the end, then print or save as a signed PDF.

Privacy note: Your answers stay in your browser. FloodPath does not upload, store, or automatically email this form. When finished, choose Print / Save Signed PDF, save it, and send it to your adjuster.

Answer what you know.
If something does not apply, leave it blank or choose Not Applicable.
You can print/save the completed packet at the end.

Contact & Claim Information

Named Insured / Policyholder

Policy Number

Claim Number

Date of Loss

Address of Loss Location

Mailing Address, if different

Best Contact Number

Alternate Contact Number

Email Address

Agent Name

Agent Phone

Agent Email

Ownership & Occupancy

Month/Year or Year Building Constructed

Month/Year or Date Property Purchased

Risk is Owned / Rented / Leased

Name the deed/title is in

List all parties with ownership interest, including spouses

Occupancy Type

Is this your primary residence, having lived here at least 80% of the last 365 days?

How many months of the year do you live here?

Lived here since

If seasonal, where is your primary residence?

Do you occasionally or permanently rent any portion of the home/building?

If yes, explain rental/lease use

Are you part of a Condo, Co-Op, or HOA Association?

If yes, Association / Management Company contact info

Building Details

Risk Type

Number of floors in building, including basement

Is the building a split level?

How many rooms are in this building?

Foundation Type

What areas of your property were flooded?

Have you made major/substantial improvements since purchase?

Describe renovations/improvements with date and amount, if known

Mortgage, Lienholders & Other Insurance

First Mortgage / Lienholder

First Mortgage Loan #

Second Mortgage / Lienholder

Second Mortgage Loan #

Home Equity / HELOC

HELOC Loan #

Other lienholder

If mortgage paid off, when?

Do you have a homeowner’s policy or other insurance besides this flood policy?

Other Insurance Carrier / Policy # / Building & Contents limits / Does it cover flood?

If yes, did you have damage not caused by flood? Explain.

Do you have excess flood coverage for building? Amount?

Do you have excess flood coverage for contents? Amount?

Prior Flood Losses

Has this property/building ever suffered prior flood losses?

List year/date, amount, whether insured at time of loss, and whether repairs were made

Do you have repair invoices, receipts, cancelled checks, estimates, or photos from prior repairs?

Floodwater Details

Where did the water come from?

Lake / river / stream name, if applicable

Nearest body of water to the home/building

Approximate distance from nearest body of water

Date water entered structure

Time water entered structure

Date water exited/receded from structure

Time water exited/receded from structure

Length of time water remained in structure

Exterior water height

Interior water height

Floodwaters were

Contents, Mitigation, Contractors & Advance

Are contents/personal property being claimed?

Do all contents being claimed belong to you or a household member?

If rental property, do you own contents in the property?

If contents are claimed, have damaged items been photographed before disposal?

Have you contacted or used professional mitigation services?

Mitigation company contact information

Will you use a General Contractor to oversee repairs?

General Contractor name / address / phone

Would you like an advance payment?

Advance requested: Dwelling amount / Contents amount

If advance not requested, explain why

Where would you like settlement/advance checks sent?

Receipts, Acknowledgements & Signature

Did you receive a copy of the Flood Claims Handbook?

Did you receive ICC information/pamphlet?

Did the adjuster offer an advance payment toward your loss?

Additional comments

Printed Name

Title / Relationship, if applicable

Signature Date

Typed Signature

Review, Sign, Print / Save PDF

Review your answers below. Sign using typed signature or draw your signature, then click Print / Save Signed PDF.

Dwelling Flood Field Questionnaire

Completed questionnaire for adjuster review.