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3. Village of Skokie - Flood Damage Questionnaire
   The purpose of this questionnaire is to help the Village of Skokie identify areas with flooding problems. Although completing this questionnaire is voluntary, your response will help in the engineering study to determine potential solutions to the flooding problems.
5. Name:
7. Address:
9. E-mail:
11. Telephone:
13. 1. Is your property:

    1. Single-Family Residence
    2. Multi-Family Residence
    3. Business/Commercial
14. Other:
16. 2. How long have your lived (or worked) at this address? (years)
18. 3. How old is the building? (years)
20. 4. If flooding occurs on your property, where is the primary location(s)?

    1. Basement
    2. First Floor
    3. Backyard

    1. Front Yard (not parkway)
    2. Garage
    3. None
22. 5. How many times in 2020 did the street in front of your house flood?
24. 6. How long does it take for the water to go down (please specify which areas are being referenced if using different time frames for different areas, i.e. street, yard, or basement).
26. 7. Flooding in your home occurs from what source? (see figure below)

    1. Sanitary sewer backup through floor drain
    2. Seepage through basement floor and/or wall cracks
    3. Sump pump reservoir backup (Sump pump failure)
    4. Overland flow through (basement window, doorway, first floor window)
27. If overland flow, please list all applicable:
29. Other:
31. 
33. 8. Have you tried any measure to flood proof your residence? (If so, please explain, i.e. sump pumps, check valves, overhead sewer, drain plug, etc.)
35. 9. Are you participating in the National Flood Insurance Program?

    1. Yes
    2. No
37. 10. Do you have an insurance rider for sewer backup?

    1. Yes
    2. No
39. 11. If you have had structure flooding, please describe the extent of flood damage that has occurred (including the date, depth of the water, duration of the flood (hours), and value/content of damage to your building).
41. Flood Event:
    (Date)
42. Depth of Flood (Feet)
    Please indicate what floor (basement, first floor, etc.)
43. Duration of Flood:
    (Hours)
44. Value of Damage ($):
    Please specify if it was building damage or content
46. Flood Event:
    (Date)
47. Depth of Flood (Feet):
    Please indicate what floor (basement, first floor, etc.)
48. Duration of Flood:
    (Hours)
49. Value of Damage ($):
    Please specify if it was building damage or content
51. Flood Event:
    (Date)
52. Depth of Flood (Feet):
    Please indicate what floor (basement, first floor, etc.)
53. Duration of Flood:
    (Hours)
54. Value of Damage ($):
    Please specify if it was building damage or content
56. 12. If applicable, please indicate which date above the depth of flood reached 'High Water Mark.'
    High Water Mark refers to the peak level reached by the flood waters outside your home.
58. 13. Please write any additional comments below and include any copies of pictures or sketches of the house and floodwaters in the area.
60. Comments:
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field