Power Outage Client Questionnaire Check the type of power outage you experienced: Residential Power Outage Commercial Power Outage Residential Outage First, we will begin with your Residential Outage claim. I. Residential Outage - Personal InformationYour Name First Last Residential Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residential Email Residential Home PhoneResident Mobile PhoneResident Work PhoneSSN DOB MM slash DD slash YYYY Occupation Marital StatusMarriedNot MarriedIf Married, Name of Spouse II. Residential Outage - Emergency ContactsResidential Emergency Contact 1 Name Residential Emergency Contact 1 PhoneResidential Emergency Contact 1 Relationship Residential Emergency Contact 2 Name Residential Emergency Contact 2 PhoneResidential Emergency Contact 2 Relationship III. Residential Outage - Power OutageResidential Claim - Name of Utility Company Residential Claim - When did you first experience a power outage? Residential Claim - When did you last experience a power outage? Residential Claim - Approximately how many hours were you without power between the time your power first went off and when it came back on permanently? Residential Claim - Did you have intermittent power between the first and the last power outage? Yes No IV. Residential Outage - Property DamageResidential Claim - Did you have any property damage as a result of the power loss? Yes No Residential Claim - Who was/were your insurer(s) at the time of the power loss? Residential Claim - Did you file an insurance claim to recover for the property loss? Yes No V. Residential Outage - Personal InjuryDid you suffer any injuries as a result of the power loss? Yes No Did you experience emotional distress or mental anguish as a result of the power loss? Yes No Commercial Outage Next, we will cover your Commercial Outage claim. I. Commercial Outage - Business InformationBusiness Name Business Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code DBA or AKA Name Nature of Business Size / Number of Employees Business Contact Person Relationship to Business Owner of Business Owner Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Commercial Claim PhoneCommercial Claim Mobile PhoneCommercial Claim Work PhoneCommercial Claim Occupation Commercial Claim Email State of Incorporation or Organization Date of Incorporation or Organization MM slash DD slash YYYY Business Type (LLC, LP, etc.) EIN II. Commercial Outage - Emergency ContactsPlease list two people that know how to contact you:Commercial Emergency Contact 1 Name Commercial Emergency Contact 1 PhoneCommercial Emergency Contact 1 Relationship Commercial Emergency Contact 2 Name Commercial Emergency Contact 2 PhoneCommercial Emergency Contact 2 Relationship III. Commercial Outage - Power OutageCommercial Claim - Name of Utility Company Commercial Claim - When did you first experience a power outage? Commercial Claim - When did you last experience a power outage? Commercial Claim - Approximately how many hours were you without power between the time your power first went off and when it came back on permanently? Commercial Claim - Did you have intermittent power between the first and the last power outage? Yes No IV. Commercial Outage - Property DamageCommercial Claim - Did you have any property damage as a result of the power loss? Yes No V. Commercial Outage - Business Income LossDid you have any loss of business income as a result of the power loss? Yes No Additional comments regarding your commercial power outage:PLEASE UPLOAD A COPY/PICTURE OF YOUR DRIVER’S LICENSE HERE:Accepted file types: jpg, gif, png, pdf, Max. file size: 6 MB.PLEASE UPLOAD A CURRENT POWER UTILITY BILL TO THIS QUESTIONNAIRE HERE:Accepted file types: jpg, gif, png, pdf, Max. file size: 6 MB. This completes the questionnaire. Please click SUBMIT and we will reach out to promptly.