Your Information:
Your Name:*
Address:
Nearest Cross Street:
City/State/Zip Code:*
Phone: Fax: Email:*
Building or Structure Information:
Do you know the flood zone the the structure is located in? Yes No If yes, what zone:
Do you have an elevation certificate or survey indicating the lowest (bottom) floor elevation of your structure? Yes
No
If yes, what elevation:
What year was the structure built?
Is this your primary residence?
Yes
No
Do you own the structure or are your renting?
Own
Rent If you own, do you have a mortgage?
Yes
No
What type of structure is it? Single Family
Condominium
Non-residential
2-4 Family
Mobile Home
How many floors does the structure have?
1
2
3
4
5
6
Is there a basement? Yes
No
Is the property located near a lake, river, or the ocean?
none
lake
river
ocean
What is the replacement value of the structure?
Optional Contents Coverage:
Contents coverage is available with your Flood Insurance Policy or separately, What amount of contents coverage would you like.
None
$25,000
$50,000
$100,000
$200,000
$300,000
$500,000
$750,000
$1,000,000
$2,000,000
$3,000,000
Comments questions and suggestions:
Other comments/questions:
This
page is provided as a service to you. It is not possible to bind any new
coverage from this request. If you have NOT received your confirmation
from us within 24 hours the same or next business day, please contact
us. NO COVERAGE IS CONSIDERED BOUND UNTIL YOU RECEIVE OUR CONFIRMATION .
Thank you for your understanding.