Township of Mapleton Flood Damage Reporting Form
As a result of the June 23, 2017 flood event, the Township of Mapleton is requesting that everyone please use this form to report any sustained damages to your property. This information will allow the Township of Mapleton to provide information to the Province of Ontario regarding the extent of damages to our municipality. It will also assist us in determining eligibility for provincial disaster financial assistance. Submission of this form does not guarantee compensation for your submitted damages, but acts as a record for processing purposes of potential claim reimbursement from the Ontario government which you may qualify for. Personal Information contained on this form is collected pursuant to the Freedom of Information and Protection of Privacy Act/Municipal Freedom of Information and Protection of Privacy Act and will be used for the purpose of gathering information and/or responding to your request.
Name of person completing this form
*
First Name
Last Name
Phone Number (Day)
*
-
Area Code
Phone Number
Phone Number (Night)
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
Postal / Zip Code
Address where damage was sustained (if different from home address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Incident
*
/
Month
/
Day
Year
Date
Do you own or rent the affected property?
*
Own
Rent
If you rent, please provide the name, address and phone number of your landlord or property owner:
What type of property was affected?
*
Residence
Business
Farm
Not for profit
Other
If 'Other' please describe
What was the cause of damage to the affected property?
*
Overland flooding from lake or river
Seepage from groundwater
Sewer back up
Other
If 'Other' please describe events, how damage began and conditions inside/outside of your property
Duration of the condition that caused the damage (if known)
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01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Were you, or was someone else, present at the time of the event?
*
Yes
No
If 'Yes', who was present (Name)?
Please describe and detail any damages that were sustained
*
Are you insured?
*
Yes
No
If 'Yes', by whom (Name)?
Have you contacted your insurance company?
*
Yes
No
If 'Yes', when did you contact your insurance company?
/
Month
/
Day
Year
Date
What is the estimated total financial loss to structure and contents?
Are any of the damages listed above not covered by your insurance company? If so please list them below.
During the event, were any of your utilities disconnected? Please check all that apply.
Hydro
Natural Gas
Water
Sewer
Other
If 'Other' please describe
During the event did you require other accommodations?
*
Yes
No
If 'Yes', please explain including the location of accommodation and duration of stay
Did you or do you still require any outside assistance? Or, do you have any questions for which you require someone from the Municipal office to contact you?
*
Yes
No
If 'Yes', please describe the nature of assistance or question
I hereby certify that the information contained on this form is true, correct and complete to the best of my knowledge
*
Yes
Submit
Should be Empty: