General Information
Name:
Address:
City:	State:   Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM   PM
Email Address:
Property Address (if different):
City:	State:   Zip:

Current Flood Insurance Information
Company Name (not agency):
Policy Expiration Date:	Policy Type: Primary Secondary

Home Information
How Long At Present Address:	Year Home Was Built:
Lender Name:
Lender Address:
Sq. Footage (excluding garage and basement):	sq. ft.         # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other	Frame Stucco Veneer Masonry Other	Asphalt Shingle Wood Shingle Tile or Slate Other	Basement Crawl Space Slab Other	1 Car 2 Car 3 Car 4 Car None
		Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Coverage Desired
Deductible's:	Dwelling: $500 $750 $1,000 $2,000 $5,000	Contents: $500 $750 $1,000 $2,000 $5,000
Dwelling Coverage:	Select preset limit below: $25,000 $30,000 $35,000 $45,000 $50,000 $60,000 $65,000 $75,000 $85,000 $90,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000	Or enter your own limit (can't exceed $250,000): $
Contents Coverage  (Personal Property):	Select preset limit below: $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $45,000 $50,000 $60,000 $65,000 $75,000 $85,000	Or enter your own limit (can't exceed $85,000): $
Your Personal Property is Located:	Basement Only   Basement and Above   Lowest Floor only above ground level (basement not incl)   Lowest floor above ground level and above

 

Miscellaneous Information
Do you qualify as a small business risk?:	Yes     No
Is building your principle residence?:	Yes     No
Is the building in the course of construction?:	Yes     No
Is insured property owned by state government?:	Yes     No
Is your building elevated?:	Yes     No
Is your building in a special flood hazard area? (if not certain leave blank):	Yes     No
FEMA (flood rate zone) (if not certain leave blank):	A AE AH AO AR A99 D V VE X Other Not Known

 

Additional Comments

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