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FloodPath Residential Flood Field Questionnaire

Merged residential/private flood questionnaire built from IA firm field survey templates, with duplicate fields removed.

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Download FloodPath Residential Flood Field Questionnaire DOCX

A. Claim & Contact Information

Policyholder / Named Insured: __________________________________________Claim Number: ____________________ Policy Number: ____________________Date of Loss: ____________________Loss Location / Risk Address: __________________________________________City: ____________________ State: ____________________ ZIP: ____________________Mailing Address, if different: __________________________________________Best Contact Number: ____________________ Alternate Contact Number: ____________________Preferred Email: __________________________________________Agent Name: ____________________ Phone: ____________________ Email: ____________________

B. Ownership, Occupancy & Use

List all parties with ownership interest, including spouses even if not on deed: __________________________________________Additional owner / spouse / named insured and relationship: __________________________________________Name recorded on deed/title: __________________________________________Do you own the building? ☐ Yes ☐ NoRisk is: ☐ Owned ☐ Rented ☐ LeasedProperty type: ☐ 1 Family ☐ 2-4 Family ☐ Mobile Home ☐ Business/Mixed Use ☐ OtherOccupancy: ☐ Primary Residence ☐ Seasonal Residence ☐ Rental PropertyPrimary residence occupied at least 80% of last 365 days? ☐ Yes ☐ NoHow 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/lease any portion of the home/risk? ☐ Yes ☐ No Explain: __________________________________________If rental property and contents are claimed, do all claimed contents belong to you or a household member? ☐ Yes ☐ No ☐ N/AAre you part of a Condo, Co-Op, or HOA Association? ☐ Yes ☐ NoAssociation management company contact: Name ____________________ Phone ____________________ Email ____________________

C. Building Details

Month/Year or Year building constructed: ____________________Month/Year or Date purchased: ____________________Number of floors including basement: ____________________Is the building split-level? ☐ Yes ☐ NoHow many rooms are in the building? ____________________Foundation type: ☐ Piles ☐ Piers ☐ Slab-on-grade ☐ Block Wall ☐ Basement ☐ Crawlspace ☐ Elevated/Enclosure ☐ OtherAreas flooded: ☐ Entire House ☐ Partial House ☐ Detached Garage ☐ Basement ☐ A/C Unit ☐ Shed ☐ Crawlspace ☐ Utility Room ☐ Finished Area Below Elevated Floor ☐ Other

D. Mortgage / Lienholder Confirmation

Claims checks may list current lienholders as payees. List all current lienholders.First Mortgage: __________________________________________ Loan # ____________________Second Mortgage: __________________________________________ Loan # ____________________Home Equity / HELOC: __________________________________________ Loan # ____________________Other lienholder: __________________________________________ Loan # ____________________If mortgage was paid off, date/year paid off: ____________________

E. Other Insurance / Excess Coverage

Do you have a homeowner’s policy or other insurance besides this flood policy? ☐ Yes ☐ NoIf yes, company/carrier: ____________________ Policy #: ____________________Did you have damage not caused by flood? ☐ Yes ☐ No Explain: __________________________________________Does any other policy cover flood damage? ☐ Yes ☐ No ☐ Don’t KnowDoes any other policy cover sewer backup? ☐ Yes ☐ No ☐ Don’t KnowOther insurance building limit: ____________________ Contents limit: ____________________Do you have excess flood coverage for building? ☐ Yes ☐ No ☐ Don’t Know Amount: ____________________Do you have excess flood coverage for contents? ☐ Yes ☐ No ☐ Don’t Know Amount: ____________________Additional other insurance carrier/policy/limits: __________________________________________

F. Prior Flood Losses

Has this building/home ever suffered prior flood losses? ☐ Yes ☐ No ☐ UnknownPrior loss #1: Date/Year ____________________ Amount Paid ____________________ Insured at time? ☐ Yes ☐ No Repairs made? ☐ Yes ☐ NoPrior loss #2: Date/Year ____________________ Amount Paid ____________________ Insured at time? ☐ Yes ☐ No Repairs made? ☐ Yes ☐ NoPrior loss #3: Date/Year ____________________ Amount Paid ____________________ Insured at time? ☐ Yes ☐ No Repairs made? ☐ Yes ☐ NoIf prior repairs were completed, provide paid invoices, receipts, canceled checks, estimates, photos, or other repair documentation when available.

G. Flood Event Details

Nearest body of water: __________________________________________Approximate distance from building/risk: ____________________Where did the water come from? ☐ Tidal Surge ☐ Accumulation of Rain ☐ Velocity Flow ☐ Low Velocity Flow/Ponding ☐ Lake ☐ River/Creek ☐ Drainage/Surface Runoff ☐ Other ☐ UnknownLake / river / creek name, if applicable: __________________________________________Date water entered structure: ____________________ Time: ____________________Date water exited/receded from structure: ____________________ Time: ____________________Length of time water remained in building: ____________________Exterior water height: ____________________ Interior water height: ____________________Floodwaters were: ☐ Clean ☐ Dirty/Muddy ☐ Sewage ☐ Don’t KnowAdditional flood/source comments: __________________________________________

H. Improvements / Renovations

Since you have owned the property, have you made major/substantial improvements or renovations? ☐ Yes ☐ NoImprovement #1 type/description: __________________________________________ Date: ____________________ Amount/Value: ____________________Improvement #2 type/description: __________________________________________ Date: ____________________ Amount/Value: ____________________Additional renovation details: __________________________________________

I. Mitigation, Cleanup & Contractor Information

Have you contacted professional water mitigation services? ☐ Yes ☐ NoMitigation company name/contact: __________________________________________Do you plan to contact/use a water mitigation company? ☐ Yes ☐ No ☐ UnknownWill you use or hire a General Contractor to repair/reconstruct flood damage? ☐ Yes ☐ No ☐ UnknownGeneral Contractor name: ____________________ Address: ____________________ Phone/Contact: ____________________Please keep all photos, invoices, estimates, drying logs, receipts, and mitigation documentation.

J. Advance Payment / Settlement Check Mailing

Did the adjuster offer an Advance Payment? ☐ Yes ☐ NoWould you like/request an advance? ☐ Yes ☐ No ☐ Not ApplicableIf advance requested, Dwelling amount: ____________________ Contents amount: ____________________If no advance requested, reason: __________________________________________Where would you like the settlement/advance check sent? __________________________________________

K. Contents Documentation

If contents coverage applies and contents are claimed, do all claimed items belong to you or a household family member? ☐ Yes ☐ No ☐ N/AHave photos been taken of each damaged contents item before disposal? ☐ Yes ☐ No ☐ N/AFor high-value items, list model/serial numbers and provide receipts, online purchase records, or comparable replacement support when available.I agree not to discard damaged contents, except perishables, until documented/reviewed when contents coverage applies. ☐ Agree ☐ N/A

L. Receipt Confirmations, Acknowledgements & Signature

I acknowledge receipt/access to the NFIP Flood Claims Handbook. ☐ Yes ☐ NoI acknowledge receipt/access to ICC information/pamphlet. ☐ Yes ☐ NoI acknowledge that neither the adjusting company nor the adjuster has authority to approve or deny any portion of this claim or authorize payment. ☐ AgreeI acknowledge the terms of salvage and subrogation recovery by the insurance carrier as set forth in the policy. ☐ AgreeI understand that the SFIP requires a signed and sworn Proof of Loss within 60 days after the loss unless extended in writing, and failure to comply may result in denial. ☐ AgreeI certify/verify/state under penalty of perjury under the laws of the United States of America that the foregoing is true and correct to the best of my knowledge. ☐ AgreePrinted Name: ____________________ Signature: __________________________________________ Date: ____________________Additional Insured Signature: __________________________________________ Date: ____________________Email Address for completed copy: __________________________________________Additional Comments: __________________________________________

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Coverage Disclaimer

FloodPath provides general claim communication and documentation guidance only. Field adjusters cannot approve/deny coverage or authorize payment. Final claim decisions are made only by the Carrier.