Please fill out the information below and press the submit button at the end. You will be notified when your questionnaire is processed. Thank you.

1. Property Owner Information:
First Name : *
Last Name : *
Street Address : *
City : * State : * Zip Code : *
E-mail Address:
Home Phone Number with Area Code : ( ) - *
Work Phone Number with Area Code: ( ) - extension:

* Above Information Required

2. How Long have you lived at this address?: years months

3. What is the approximate age of the house?: years months

4. What was the most recent date you experienced a sanitary sewer backup?
Please use the following format: i.e. mm/dd/yyyy: example: 03/16/2004

5. Have you experienced water in your basement from surface water flooding?:
Yes No NA

6. If the answer to question seven was yes, please indicate the source:
Window Well Cracks in the basement walls Cracks in the basement floor Sump Pit
Other

7. What was the extent of the most recent sewer backup?:
Minor: Wet areas around floor drain. Moderate: Water accumulation. Severe: Floor surface covered (Please indicate water depth in inches) inches

8. What was the extent of the most severe sewer backup?:
Minor: Wet areas around floor drain. Moderate: Water accumulation. Severe: Floor surface covered (Please indicate water depth in number format the inches) inches
What was the date of the most severe sewer backup mm/dd/yyyy: example: 03/16/2004

9. Please indicate the source of the most severe sewer backup:
Floor Drain Toilet Shower Tub Sink Washing machine standpipe
Other (Please describe)

10. Is your home equipped with either of the following devices?:
Backwater valve in your service line Sump pump.

11. Have any modifications been completed on your property to remedy the sanitary sewer backup problem?:
Yes No
If yes, please describe and indicate when completed and by whom:

12. Have any of your neighbors experienced a sewer backup during a rain event?
Yes No
If yes, please provide their names and addresses:

13. Please provide any additional information you deem relevant:

16. Have you contacted the Federal Emergency Management Agency (FEMA) or any other agency to inquire about flood damage assistance or mitigation?:
Yes No Case Number: