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2. Notice of Loss - Sewer Back-up

   The Village of Elm Grove was alerted that due to a sewer back-up during the storms of August 9 and 10, 2025, you incurred property damage or loss. Please use this form to record your loss for submission to the Village's insurance carrier and the County to enter for their application for FEMA aid. Federal aid would only be available if a Presidential Emergency Declaration or Major Disaster Declaration is issued. No such declaration has been made at this time, and it is unknown whether one will occur.

   Please note this claim form is not a guarantee of payment.

   The statutory time frame to report a claim is 120 days from incident.

4. First Name*
5. Last Name*
7. Phone Number*
8. Email*
10. Address of Property Where Loss Occurred*
12. City*
13. State*
14. Zip*
16. Did the Sewer Back-up into your Property?*

    1. Yes
    2. No
    3. Unsure

    Please answer this question honestly. Even if flooding you experienced was not due to a sewer back-up, you still may be eligible for FEMA aid if it becomes available.

18. Please Explain How The Loss or Damage Occurred*
20. Itemization of Damages and Cost*

    Please provide an itemized list of damaged items due to the sewer back-up, including the cost for each item.

22. Total Cost of Damages/Loss*
23. Amount Covered By Homeowners Insurance*

    Any claim filed with the Village's insurance carrier will be secondary to the homeowners insurance. If you have not already received notice of coverage/lack thereof from your insurer, please wait to complete this form.

25. Please submit photos showing the sewer damage such as the height or access point of the water. Photos should be immediately following damage prior to any restoration efforts were made. If you have additional photos to share, please send to cturner@elmgrovewi.org and esowl@elmgrovewi.org referencing the property address.

27. Photo 1
28. Photo 2
29. Photo 3
31. Photo 4
32. Photo 5
33. Photo 6
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field