City and County of Honolulu Department of Emergency Management

2018 Tropical Storm Olivia Damage Report Form

Please use this form to report damages to your home as a direct result of Tropical Storm Olivia, which affected Oahu

September 11-13, if you have not previously reported damages to the American Red Cross or to the City and County of Honolulu. This survey is intended to help the City and County of Honolulu identify storm-related damage and is not intended to be an application for assistance with cleanup and recovery.

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* 1. Name

Last

First

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* 2. Are you filling this out on behalf of someone else (e.g., a parent, an unavailable homeowner)?

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* 3. Address of the affected property

Street Number

Street Name

Unit/Apt

City

Zip

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* 4. Tax Map Key (TMK), if available

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* 5. Is this your primary residence?

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* 6. Are you currently staying at this address?

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* 7. Do you own or rent this residence?

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* 8. Best phone number to contact you

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* 9. Email address

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* 10. What insurance coverage do you have? (Check all that apply)

Homeowners

Personal Property

Additional Living Expenses

Renters

Hurricane

Flood

Other

No Insurance

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* 11. Please describe in detail the damage to your property (e.g., roof blown off, 6 in. of flooding in home)

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* 12. Damages are to: (Check all that apply)

Bedroom

Kitchen

Living Room

Bathroom

Dining Room

Roof

Septic System

Electrical System

Foundation

Home Structure

Other

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* 13. If you experienced flooding, did the flood waters go over your electrical outlets?

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* 14. If you experienced flooding, how high was the flood water inside your home (inside your living space)?

feet

inches