SAN JUAN COUNTY DEPT OF EMERGENCY MANAGEMENT

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Phone Outage Estimated Economic Impact Worksheet for Businesses and Other Organizations

Please fill out this form to help us determine the economic impact of the November 2013 communications outage on your business or organization. Note that there is no financial support currently available from State or Federal Government, nor a guarantee of future support. This is just the first step in assessing the impact and need.

INSTRUCTIONS: Please complete this form, print a copy for your records, and submit by pressing "Send Form" at the bottom of the page. If you have questions or need help, please email dem@sanjuandem.net or call 360-370-7612.

If you prefer, form may be faxed to 378-7125, or mailed to SJCDEM P.O. Box 669 Friday Harbor, WA 98250.

If a required field is not relevant, please enter NA.

Name of Business or Organization *

Owner Last Name *

Owner First Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Contact email address *

Contact Phone Number *

Street Address of Affected Business

Same as Above

Address 1

Address 2

City

State

Zip Code

Dates of Impact From Outage *

Please note the exact dates that loss occurred. Please detail below. For revenue figures, please be as exact as possible, and consult actual financial records to ensure figures match as closely as possible to final amounts.

YYYY

Dates of Impact To *

YYYY

Please approximate your loss of revenue directly due to outage so far: *

Do you have or will you have documentation that can demonstrate losses?

Yes

Unsure

Clear selection

Do you expect additional revenue losses going forward? *

Yes

Unsure

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

Please provide an explanation of what adverse economic effects the phone outage had on your business or organization

Did you have to lay off staff or reduce workers' hours during the outage? *

Yes

If yes to question above, please describe specifics, including approximate value of unpaid wages:

Did you have to add staff or increase staff hours due to increased workload during outage?

Yes

Clear selection

If yes to question above, please describe specifics, including approximate value of extra wages paid:

Submit

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