Name _________________________________ Phone __________________
Address ________________________________________________________
Is this your primary residence? Yes No
Damage to: Business ________ Home _______ Contents ________
Description of Damage _____________________________________________
________________________________________________________________
Pre-disaster market value of the property _____________________________
Dollar estimate of the damage _______________________________________
Insurance carrier __________________________________________________
Name of owner if different from above: _______________________________
__________________________________________________________________
Please return form to: Ulster County Emergency Management
238 Golden Hill Lane
Kingston, NY 12401
Phone 845-331-7000
Fax 845-331-1738
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