Corps of Engineers Civil Works Questionnaires Generic Clearance

BUSINESS FLOOD LOSS SURVEY

(Personal Interview)

OMB 0710-0001

Expires: 30 November 2012

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BUSINESS FLOOD LOSS SURVEY

Interview date _______________________

By ____________________________________

Firm name ___________________________________________________________

Address ___________________________________________________________

___________________________________________________________

Type of

Business ___________________________________________________________

Building type ___Block/Brick ___Steel ___Wood ___Metal

(Check appropriate block)

Building size _____feet by _____feet: = ______________square feet

(Not including basement)

Basement size _________square feet of finished area

_________ Square feet of unfinished area

Number of floors (including basement, if any) __________

Ground elevation______________

How high in feet and inches did the water from ______ (year) flood get on the inside of this building relative to the first floor of the building?

______ FEET; _______ INCHES (ABOVE, BELOW) First Floor Level

[CIRCLE]

Please indicate the total replacement value of the following items and the amount of damage you estimate occurred from the (year) flood. (Include only items owned or managed by your business.)

	Replacement Value	(year)Flood Actual Damage or Cost
Damage to Transportation
Roads, bridges, streets, walks, parking
Rail beds and tracks
Rerouting trains, trucks, cars, & buses
Docks and loading facilities
Damage to Buildings
Foundation and supports
Floors (mark one) ___Steel ___Concrete ___Wood
Floor covering (mark one) ___Ceramic ___Linoleum ___Carpet
Exterior walls and insulation (mark one) ___Metal ___Wood ___Block/brick
Windows
Interior walls and ceilings
Doors and moldings

Damage to Building Utilities Indicate location: B=Basement, G=Ground floor, I=Intermediate floors, R=Roof
Sewer systems ___Storm ___Industrial ___Sanitary ___B ___G ___R
Water supply systems ___Treatment ___Pipes ___B ___G ___R
Water systems ___Hot water ___Softening ___B ___G ___R
Communications systems ___B ___G ___R
Electric power transformers ___Pole ___Ground
Electrical service entrance and meters ___B ___G ___R
Engines/generators/alternators ___B ___G ___R
Other Electrical control panels and circuit breakers ___B ___G ___R
Wiring switches, outlets, lighting ___B ___G ___R
Fuel supply ___Oil tanks ___Gas pipes/meters ___B ___G ___R
Heating ___Oil ___Gas ___Elect. ___Air ___Water ___B ___G ___R
Air conditioning ___Gas ___Electric ___Cool ___Purify ___Dehumidify ___B ___G ___R

Damage to Equipment, Appliances, and Furniture
___Conveyors ___Elevators ___Escalators
Foundry furnaces and welding equipment
Machine tools and patterns
Other motors and engines
Compressors
Built-in refrigeration units
Hand and paint tools
Other equipment
Display cases, counters, and bins
Appliances ___Oven ___Refrigerators ___Other ______________________ ______________________________ ______________________________
Vehicles kept at this location
Damage to:
Parts/raw materials
Partly assembled/processed product
Inventory
General Costs
Fighting the Flood
Evacuation ___Owner ___Tenant
Number of employees out of work
Value of lost wages
Removal of debris and damaged items
Disinfecting, other cleaning and rehabilitation
Replacement of records
Loss of gross income due to interruption of business
Loss of net income due to interruption of business
Increased alternative operating costs

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