Flood Quote

Request for Flood Insurance Questionnaire
1. Date: Need By (Date):
2. For inspection:   Mobile #: Work #:  Home #: Fax #:
3. Contact Name:     Email:
4. Mailing Address: City: County:
5. Do you have an Elevation Certificate?  Yes No     |       Do you know the Flood Zone?:
6. How many Families / units in Building?: How many floors in Building?:   Mortgage Amount : $
7. Do you want building  and  / or content coverage:    Building: $         Content: $
8. If Building coverage desired, what deductible? $1,000 $2,000 $3,000 $4,000 $5,000               Content Coverage deductible? $1,000 $2,000 $3,000 $4,000 $5,000
9. What is the replacement cost of the Building?
10. Is your building elevated on: Piles Piers Posts
11. Does your building have a basement?     Yes No       |     Is the Basement finished?  Yes No
12. What Items are in the Basement: (ie. Boiler, Dishwasher etc. Please list all that apply)
13. Is there are Garage?   Yes:   No:
14. What company insures you now: Current premium: $
15. Why do you want to switch:     Pricing: Switch Agent: Being Cancelled: Cancelled:
Finish
16. Referred by: Please Select Friend Net Quote Internet Yellow Pages Newspaper    Other:
Notes:
Reproduction of this Questionnaire is restricted unless permission is given.

 
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