FLOOD INSURANCE QUOTE
[Please enter information on the house you wish to insure for the risk of flood.]
Note: * Denotes a required entry.
HOUSEHOLD & CONTACT INFORMATION
Name*:
Address*:
City, State, Zip*:
Primary Phone*:
Secondary Phone:
Email*:
Do you currently have flood insurance?*:YesNo
Best method to contact you*:PhoneEmailEither Phone or Email
Best time to contact you:AMPMAnytime
FLOOD INSURANCE COVERAGE DESIRED
Is Flood Insurance required by Mortgage / Loan?:YesNo
Building Coverage
Address same as contact info?:YesNo
Address of Building:
City, State, Zip:
Dwelling Coverage Desired:
Contents Coverage
Where are Contents Located? (check all that apply):Basement1st Floor2nd FloorOther
Total Amount of Contents:
FLOOD RATING INFORMATION
(if known)
Flood Zone:AE / AO (River Flood Risk)VE (Coastal Flood Risk)X (above 100-year floodplain)Unsure
Elevation Certificate?:
LOMA (Letter of Map Amendment)?:YesNo
Prior Flood Insurance:YesNo
Any prior Flood Insurance claims in past 3 years?:NoneOne claimTwo claimsMore than two claims
BUILDING INFORMATION
Type of Building:Single Family HomeDuplexApartment BuildingMobilehomeCommercial BuildingOther
How is building Occupied?:Primary ResidenceSecondary / Vacation ResidenceRental Dwelling Other
Number of Stories:One StoryTwo StoryOther
Basement?:YesNo
Garage:No GarageAttached GarageDetached Garage
Verification:
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