Form Center

2. Basement Back-Up Flooding Survey

4. First Name*
5. Last Name*
7. Address*
9. Phone
10. Email Address
12. How long have you lived at this address?
14. Have you experienced basement back-up flooding?
    -- Select One --YesNo
16. Have you experienced backyard flooding?
    -- Select One --YesNo
18. Have you experienced street flooding?
    -- Select One --YesNo
20. When was the date of your most recent flood event?
22. How many times have you experienced basement back-up flooding in the past year?

    1. One to two times
    2. Three to four times
    3. Five or more times
24. Have you informed your insurance carrier?
    -- Select One --YesNo
26. Have you filed a claim for damages?
    -- Select One --YesNo
28. Does the water come in from the same place each time?
    -- Select One --YesNo
30. Where is the water coming from in the basement?

    1. Floor Drain
    2. Toilet
    3. Sink
    4. Windows/Door
    5. Foundation (Walls/Floor)
    6. Unsure
32. How often does water enter your basement?
    -- Select One --After heavy rainfall eventsAfter every rainfall eventOnce a yearLess than once a year
34. Depth of water in the basement
    -- Select One --0 to 6 inches6 to 12 inches12 to 24 inches24 to 36 inches36 to 48 inchesOver 48 inches
36. Describe the characteristics of the water in the basement.

    1. Clear
    2. Muddy
    3. Slight Odor
    4. Strong Odor
    5. No Odor
    6. Other
38. Additionally describe the water in the basement.
40. Do you have a sump pump in your basement?
    -- Select One --YesNo
42. Do you have a backflow preventer on storm and/or sanitary lines?
    -- Select One --YesNo
44. Additional Comments
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field