Flood Application Form Please complete this form and we will contact you with a quote Personal Information: Last NameFirst NameBusiness NameStreet AddressCityStateZipPhoneEmail Business & Property Information:Property Street AddressCityStateZip CodeOccupancy Type Single Family Family House Condo Co-op Apartment Year BuiltFlood Map Zone NumberCurrent Elevation Certificate Yes No If Yes, how many feet above sea level?Community Flood NumberDistance to Body of Water100-500 FT500-1000 FTOver 1000 FTBody of WaterNone1-2 Car BuiltIn1-2 Car DetachedHow many stories is itWhat is the construction type?Wood FrameBrickBasementNullFullPartialWhat type of roof coveringIs the roof updated Yes No If yes, what yearAre there smoke detector at this location? Yes No Are there fire extinguishers? Yes No Are there circuit breakers? Yes No Is the electrical updated? Yes No How old is the heating/air conditioning?What is the energy sourceHas the plumbing been updated? Yes No If yes, what year was the plumbing updatedIs the plumbing cooper? Yes No Does the building have interior automatic fire sprinklers? Yes No Is there a fire alarm? Yes No Has the building been retrofitted or bolted? Yes No Claim InformationWere there any loses or claims in the last 5 years? Yes No If yes, what is the date, amount paid and description of each loss or claimCoverage InformationCurrent Insurance CompanyHow much are you paying nowWhat is the building coverage requestedWhat is the other structure coverage requestedWhat is the contents property coverage requestedBest Time to Contact YouPlease let us know the best time to call and discuss your quote Morning Afternoon Evening Anytime Or Specify OtherCAPTCHANameThis field is for validation purposes and should be left unchanged.