FloodApplication FormPlease complete this form and we will contact you with a quotePersonal Information:Last NameFirst NameBusiness NameStreet AddressCityStateZipPhoneEmail Business & Property Information:Property Street AddressCityStateZip CodeOccupancy Type Single FamilyFamily House Condo Co-op ApartmentYear BuiltFlood Map Zone NumberCurrent Elevation Certificate Yes NoIf 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 NoIf yes, what yearAre there smoke detector at this location? Yes NoAre there fire extinguishers? Yes NoAre there circuit breakers? Yes NoIs the electrical updated? Yes NoHow old is the heating/air conditioning?What is the energy sourceHas the plumbing been updated? Yes NoIf yes, what year was the plumbing updatedIs the plumbing cooper? Yes NoDoes the building have interior automatic fire sprinklers? Yes NoIs there a fire alarm? Yes NoHas the building been retrofitted or bolted? Yes NoClaim InformationWere there any loses or claims in the last 5 years? Yes NoIf 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 AnytimeOr Specify OtherCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
