Flood Online Quote Request Form

Flood Online Quote Request Form
Agency Name*
Agency ID Number*
Agency Phone Number*
Please enter a valid phone number.
Agency Fax Number
Please enter a valid phone number.
Agency Email Address*
example@example.com
Agency Contact*

First NameLast Name
NOTE: The Effective Date of coverage may change based upon when the application and premium are received at the company. The premium is considered received when the check arrives in our offices. However, if payment is made online using credit card or ACH, it is considered received on the date of the credit card or ACH transaction.

Property Address
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Is this building located in the city limits?*

YesNo
Insured Mailing Address same as Property Address?*

YesNo
If answered "No" above, please enter the mailing address:

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Prior Policy Expiration Date

MonthDayYear
Date
Original New Business Date

MonthDayYear
Date
Reinstatement Date

MonthDayYear
Date
Community Number
Flood Zone
Suffix
Panel Number
Zone Document Type
NFIP Policy Type
Effective Date Rule
Requested Effective Date*

MonthDayYear
Date
Property Purchase Date

MonthDayYear
Date
Is this application a rollover?

YesNo
Previous Carrier
Previous Policy Number
Is insurance required for disaster assistance?*

YesNo
Is insurance required under mandatory purchase?*

YesNo
Mortgagee Name

First NameLast Name
Mortgagee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mortgagee Loan Number
Lender Type
Second Mortgagee Name

First NameLast Name
Second Mortgagee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Mortgagee Loan Number
Is the building under construction?

YesNo
Is it walled and roofed?

YesNo
Construction (other) date

MonthDayYear
Date
Type of date
Is the property owned by state government?

YesNo
Is the building located over water?

YesNo
Occupancy Type*

Less than 50%50%-79%80% +
The insured resides here

YesNo
Number of occupancies
Is building insured's principal residence?

YesNo
Building use description
Is the coverage for the entire building?

YesNo
Building description type
Additions and extension coverage
Building diagram number
What is the square footage of the building?*
Is the building elevated?*

YesNo
Number of floors?
Is the building a condominium?*

YesNo
Severe repetitive loss property?
Has the building been substantially improved since the original date of construction?
List all equipment located below the elevated floor
Enclosure/crawlspace?*

YesNo
Estimated total square footage of enclosure/crawlspace
Building partially or entirely over water?

PartiallyEntirelyNot over water
Is building located on leased federal property?*

YesNo
Elevated floor is enclosed?

YesNo
Materials used to enclose the area below the elevated floor
Is the enclosed area/crawlspace constructed with openings (excluding doors) to allow for the passage of floodwaters through the enclosed area/crawlspace?

YesNo
Enter the number of permanent openings (flood vents) within one foot of the adjacent grade
Enter the total area of all permanent openings (flood vents) in square inches
Is the enclosed area/crawlspace used for any purpose other than solely for parking of vehicles, building access, or storage?

YesNo
Describe use of enclosed area
Does the enclosed area/garage have more than 20 linear feet of finished wall, paneling, etc?

YesNo
Lowest elevated floor is raised above the ground by
Is the building located in a mobile home park?

YesNo
Date park was established

MonthDayYear
Date
Date of permanent place on property

MonthDayYear
Date
Make
Year of manufacture
Model number
Serial number
Dimensions
# of feet long x width
Anchoring system
Does the manufactured home have skirting?

YesNo
Any extensions or additions?

YesNo
Dimensions of Extension or Addition
# of feet long x width
Manufactured home installed in accordance with
Is part of the foundation system in the water?

YesNo
Is there an attached garage?

YesNo
Estimated total square footage of garage
Are there any openings (excluding doors) that are designed to allow the passage of flood waters through the garage?

YesNo
Is the garage used solely for the parking of vehicles, building access, and/or storage?

YesNo
Does the garage contain machinery or equipment?

YesNo
Attached garage location
Does the building contain an elevator(s)?

YesNo
Enclosure type
Basement type
Building elevation certificate

Cancelof

Coverages
Building Coverage*
Building Deductible*
Contents Coverage*
Contents Deductible*
Replacement Cost*
Comments
Should be Empty:

Flood Online Quote Request Form

Direct Bill Instructions

Property Address

Coverages