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: *
*This field is required
Business Name: *
*This field is required.
Address 1: *
*This field is required.
City: *
*This field is required.
County: *
*This field is required
State:
Zip Code: *
*This field is required.
*This is not a valid Zip Code.
Enter 5 digit Zip Code
First Name: *
*This field is required.
Last Name: *
*This field is required.
Email: *
*This field is required.
*This is not a valid email.
Phone:
*This is not a valid phone.
Enter 10 digit Phone Number with no dashes.
Business Type:
Currently open for business? *
When do you anticipate re-opening?
What are your biggest challenges to re-opening?
Did your business location suffer damages?
Please Estimated physical damage (dollar amount):
Please enter only numbers
How much insurance recovery funding have you received or anticipate receiving from physical or property damage?
Please enter only numbers
If your business is not usable, what type of space do you require?
Square feet needed:
*This is not a valid Number.
Estimated length of time needed (approximate number of days):
*This is not a valid Number.
Did you lose business due to this emergency/disaster?
Start Date
*Please enter a valid date.
End Date
Please enter a valid date.
What were your business revenues during the disaster period?
*This is not a valid Number.
What were your business revenues during the same period of the prior year?
*This is not a valid Number.
Do you have business interruption insurance?
What is the amount you have received or that you anticipate to receive?
*This is not a valid Number.
Please estimate the total cost(physical and economic) to your business due to this emergency/disaster:
*This is not a valid Number.
How many employees (Full Time and Part Time) do you currently have?
*This is not a valid Number.
Have you or will you lay off employees as a result of this emergency/disaster?
Number of temporary lay-offs:
*This is not a valid Number.
Number of permanent lay-offs:
*This is not a valid Number.
Do you sell food products?
Have you registered for disaster assistance with FEMA?
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:
(Click here to register with FloridaDisaster.biz and save your Business Damage Assessment Survey)
Confirm Email Address: *
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*Emails Do Not Match.
Password: *
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Confirm Password: *
Confirm password is not matched.
*This field is required.