Whitespace
Derek Bos
Chief of Police and Emergency Manager
970-842-5001
dbos@brushpolice.org

Matt Gordon
Graduate Intern, Public Information and Website Manager
720-810-2994
mgordon@brushcolo.com

Economic Injury Worksheet

The purpose of this form is to understand the extent of economic injury in the Brush Area and to compile data for future relief efforts at the federal and state levels. All submissions are considered confidential.

Name of Business

Type of Business



Owner Details

Last Name

First Name

Work Phone

Home Phone

Email

Property Owner



Business Owner Mailing Address

Address

City

State

Zip Code

County



Business Street Address

Same as above
Yes

Address

City

State

Zip Code

County



Estimated Adverse Economic Impact

When did the impact start and what is the estimated end date?

What were your businesses' revenues during the affected damage period?

What were your businesses' revenues during that SAME period of the prior year?

Amount of business interruption insurance received or anticipated, if any:

Please provide a brief explanation of what adverse economic effects the disaster had on your business:

How many people did you employ prior to disaster?

How many did you employ after disaster?



Physical Damage to Business Property

If your business also suffered property damage, please answer the following questions:

Estimated dollar loss to:

Real Property (Building), if owned:

Contents *:

Insurance recovery expected or received for property damages:

Date form completed



Form Completed by

Title