Would You Like to Seek Financial Assistance from the Bothell Fire Fund? YES ______NO ______

The Bothell Fire Fund has been set up to support Bothell residents, businesses, and employees impacted by the fire which occurred on July 22, 2016. To better assess your immediate needs and determine how the Bothell Fire Fund Advisory Board can best help your business recover, please fill out this form to the best of your knowledge with as much information as you are comfortable sharing with us. Use additional pages if needed to fully answer questions. (If you do not need financial support from the Bothell Fire Fund you do not need to fill out this form.) While we are making every effort to support you, please know that completing this form does not guarantee disbursement of funds. We realize the answers to some of these questions may not be quantifiable yet. We will continue to follow up with people who respond to this questionnaire.
Please complete the form by Tuesday, August 2, and return to Brittany Caldwell at or drop off at the Alexa’s Café, 10115 Main St, Bothell WA 98011. Questions? Email Brittany or call at 425-485-4353.

Would you like to seek financial assistance from the Bothell Fire Fund? YES ______NO ______

Business Name:

Address: _

Owner:

Phone: ______Email: ______

PHYSICAL DAMAGE

Briefly describe physical damage to your business:

Estimated costs of physical damage (if you know):

LOSS OF BUSINESS

How long will your business be closed due to the fire?
Will you reopen your business?

When do you expect to reopen?

Estimated loss of business costs:

INSURANCE

Have you made an insurance claim? YES ______NO ______

Has a coverage determination been made yet? YES______NO ______

What is your insurance deductible or self-insured retention (SIR)?

Are there limits to what your insurance will cover? YES ______NO ______
If yes, what are the limits?

Do you have business interruption insurance coverage? YES ______NO ______

Any insurance disputes? YES ______NO ______

If yes, please describe:

EMPLOYEES

How many employees (excluding independent contractors) lost wages due to the fire?

Estimated total lost wages of employees (including owner if you work at your business)?
Have you paid employee wages out of pocket? If so, estimated cost?

Are there any other losses or impacts for your employees from the fire?

Any impacts to your business not listed above? Any additional concerns or questions?

Have you raised funds to support your business’ recovery? YES ______NO ______

If yes, please describe:

Have you received financial help form other organizations or efforts to assist you?

Do you need funding to meet immediate needs for your business? YES ______NO ______

If yes, please describe:

By your signature below, you represent to us the information you provided is correct to the best of your knowledge.

Business owner’s signature Date