Rebuild Application for Disaster Recovery | Start Healing Today

Full Name*

Email*

Phone Contact*

Address of Home Repair or Rebuild Project*

Zip Code*

Date of Loss:*

Applicant own the affected property?*

Yes

No

No, Not Affiliated

Residency*

Primary Residence

Secondary Residence

Rental (Short or Long Term)

Other

Insurance Coverage*

Insured, Fully Covered. Need education on what to do next

Insured, inadequate coverage

Insured, lapse in coverage

Uninsured, self funded. Need help identifying licensed contractors

Uninsured, low income

Uninsured

If not affiliated, or property not owned by applicant; enter owner details below

Description of Rebuild Need

Notes or Personal Message

Description of Disaster*

Structure Fire

Commercial Fire

Wildland Fire Impacting Structure

Vehicle Impact to Structure

Natural Disaster Affecting Structure (Explain Below)

Weather Disaster Affecting Structure (Explain Below)

Physical Disaster Affecting Structure(Explain Below)

Explanation of Natural, Weather, Physical or Other Disaster Affecting Structure

Structure Type

Single Story, Single Family Home

Multi Story, Single Family Home

Single Story, Multi Family Home

Multi Story, Multi Family Home

Apartment (Any)

Apartment Complex

RV

5th Wheel

Single/Double Wide Trailer

Pre-fabricated building

Level of Damage (May Require Photos)*

Total Loss; Demo and Rebuild

Heavy Loss: Heavy Fire and Smoke Damage, Structural Compromise

Moderate Loss: Moderate Fire and Smoke Damage, Structural Integrity Damaged

Minor Loss: Light Fire and Smoke Damage, Structure Components Intact

Damaged Area*

Entire Structure

Partial Structure

One Room in Structure

Contents and Items Only

Smoke Damage Only

High Risk Population*

Senior Citizen (65+)

Elderly (55+)

Veteran

First Responder

Active Duty Military

Military Reserves

Single Parent

Challenges with Health Conditions

Challenges with Disabilities

Challenges with Financial Resources

Low Income

Pregnant, single parent

Immigrant

First Generation

Family with 1 or more children under age 15

Foster Youth

Emancipated Minor

Limited English Profeciency, Non-English Speakers

Rebuild Application*

Rebuild Grant

Rebuild Loan

Either

Self funded: need education or connect with local rebuid organization

Rebuild: FireSafe Application

Contact

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