Form Page

First Name*

Last Name*

Phone*

e.g. 555-555-5555

Email*

Did you or your loved one suffer a personal injury, business loss, or home damage during the winter storm of 2021?*

Personal Injury

Business Loss

Homeowners

None of the above

Did you suffer a power outage during the recent winter storm?*

Yes

No

Were you or a loved one seriously injured as a result?*

Yes

No

What is the name of your business?*

Did your business suffer loss of electricity, loss of water or broken pipes because of the recent winter storm?*

Yes

No

Did your business lose income during the recent winter storm?*

Yes

No

How was your business impacted?*

Did your pipes in your home break or burst as a result?*

Yes

No

Please describe the damage:*

When would be a good time to call you?

Central Time