Business Name*
Business Address*
Economic region*
Business phone*
x
Contact name*
Email address*
Contact phone*
Are you an Indigenous owned business?
Type of physical location
If Other, please specify
Type of Business (specify your sector)
If Other, please specify
How long has your business been in operation: Years
Needs Identification
Has your business been impacted by wildfires in 2021?
If Yes, please explain what functions of the business were impacted and their status
If No, was your business impacted by other means? (Please explain)
If Other, please specify
Please explain how your business is being or was affected by the wildfires. (Select all the apply)
If Other, please specify
What are your immediate needs?
If Other, please specify
Please specify details of any immediate needs
Future Needs (once returned to the community if they have not returned yet)
What resources do you believe you will need within the next one to two weeks
If Other, please specify
Employees
Total number of employees at your business before the wildfires?
Have you laid off or terminated any employees post disaster?
If Yes, how many employees do you have now?
What is the status of your employees?
How many lost their homes?
Were you able to help your employees deal with the situation? (Excluding the employment impact)
If Yes, how did you help
Will your employees need assistance?
If Yes, what type of assistance (financial, etc.)
Critical papers, business records and policies
Are your critical papers/records secure/backed up?
If Yes, do you need assistance in accessing them?
Do you have business insurance?
Does your business insurance cover fire, smoke damage losses?
Does your business insurance cover loss of income, inventory and/or interruption of business?
Distribution Channels
Do you have a customer list to advise them of the status of your business?
Comments
Do you have a supplier, or wholesaler list to advise them of the status of your business?
Comments
Would you like someone to contact you regarding any specific issues or to provide additional assistance once
the situation has improved?
Notes
Phone number
Please verify that you are a real person*