Flood Insurance Form

Flood Insurance Form
Your Name*

First NameLast Name
Your Date of birth*

MonthDayYear
DOB
Please enter the legal name under which the property is registered, such as LLC, Corp, or Trust. (if applicable).
What’s your Phone Number?*
Please enter a valid phone number.Format: (000) 000-0000.
What’s your email address?*
example@example.com
What’s the home address to be insured?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary – Insured lives thereSecondary HomeSeasonal – Occupied 2–3 months per yearRented to others (Full lease tenant)Rented to others – Seasonal, (like Airbnb etc)
Detached HomeSemi-attachedTownhouseCondoCo-opMulti-unit
Single familyDuplex2 Units3 Units4 Units4+ Units
Year built*
How many units at this location?*
Name insured & FamilyRented out (DP3)
Wood FrameMasonrySteel FrameConcreteOther
Slab on Grade (Non-Elevated)Crawlspace (Elevated or Non-Elevated Subgrade Crawlspace)Basement (Non-Elevated)Elevated
YesNo
YesNo
Please upload the elevation certificate

Cancelof
For any homes that do not have accessible space below the elevation of the front door, how many stairs lead to the front door?
Number of stories:*
Square footage of the home:*
YesNo
What coverage amount is needed for the Building?
What coverage amount is needed for the Contents?
What Deductible option would you choose?*
InsuredMortgagee Lienholder
Flood InsuranceValuable Items (jewelry, artwork, etc.)Commercial InsuranceWorkers Comp InsuranceNone
YesNo
Please provide details of any claims, including what happened, the date, and the amount of the loss.*
Anything else you would want the agent to know regarding the home?
Please select the broker you are working with on this submission.*
Should be Empty: