Business Damage Assessment Survey (* is required)

Providing information in the fields below submits a survey to determine damage related to disaster impacts in Florida, and does NOT serve as an application for resources, including the Small Business Emergency Bridge Loan. Please click HERE to apply for the bridge loan. After filling out the survey, federal, state or local agencies may reach out to you through the contact information provided if you indicate your interest.

Surveys are public record and must be made available to the public and media upon request.

Event/Incident: *
Business Name: *
Business Location:
Address 1:
Address 2:
City:
County: *
State:
Zip Code:
Contact Details:
First Name: *
Last Name: *
Email: *
Phone:
Business Type:
Currently open for business? *
Did your business location suffer damages?
Type of Damage?
Physical Damage:
If your business is not usable, what type of space do you require?
Square feet needed:
Estimated length of time needed (approximate number of days):
 
Economic Damage:
Did you lose business due to this emergency/disaster?
What were your business revenues during the disaster period?
What were your business revenues during the same period of the prior year?
 
Do you have business interruption insurance?
Please estimate the total cost(physical and economic) to your business due to this emergency/disaster:
 
How many employees (Full Time and Part Time) do you currently have?
 
Have you or will you lay off employees as a result of this emergency/disaster?
Do you sell food products?
Have you registered for disaster assistance with FEMA?
If you have not registered with FEMA, please visit www.DisasterAssistance.gov
Other key factors hindering business operations (check all that apply)



Would you like to be contacted with more information about business relief services and programs?
Check the types of assistance your business is interested in receiving:



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