Business Damage Assessment FORM (* 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:
State:
Zip Code:
Contact Name: *
Contact Email: *
Contact Phone:
Business Type:
If other, Please Specify
Currently Open for Business? *
 
Did your Business Location Suffer Physical Damages?
If your business is not usable, what type of space do you require?
Square Feet Needed:
 
Estimated length of time needed: (Approx Days)
 
Did you or will you lose business due to this emergency/disaster?
What were your business revenues during the same period of the prior year?
 
Do you have business interruption insurance?
Please estimate the total cost 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?
Have you registered 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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