New Policy - High Hazard Flood Zone Insurance

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What is your full name?

What is your first name?

What is your last name?

What is your preferred phone number?

What is your email address?

Property Address

Please enter the address for the property you would like a flood insurance quote for.

Street Address Address Line 2 City State ZIP Code

New Purchase

Are you in the process of purchasing this home?

Yes
No

Residence Type

What type of residence is this?

Occupancy

Select the occupancy of the property?

Primary Residence Address

What is the address of your primary residence?

Street Address Address Line 2 City State ZIP Code

Mortgage

Do you have a mortgage?

Yes
No

Ownership Structure

Is this property owned by a Trust, LLC or Limited Partnership?

Yes
No

Entity Name

Please enter the name of the Trust, LLC or Limited Partnership:

Year Built

What year was this property built? (YYYY)

Substantially Improved?

Has the home been substantially improved since it was built? (Over 50% of the market value was spent to renovate)

Yes
No
Not sure

Approximate Square Footage

What is the approximate square footage of this property?

Stories

How many floors does this residence have? (Not including a basement/attic)

Construction

What is the primary material used in the construction of this property?

Renovations

Are you planning any major renovations to this home?

Yes
No

Renovation Details

Please tell us more about your renovation plans.

Budget	Start Date	Length of Project (# of Months)

Renovations Description

Please provide a brief overview of the renovation project. (i.e. Kitchen remodel, etc.)

Outbuildings

Are there any outbuildings on the property that you want flood coverage for? (i.e. pool houses, detached garage, etc...)

Yes
No

Outbuildings Description

Please tell us about the outbuildings you want flood coverage for.

Foundation Type

Please select your property's foundation type:

Please describe the foundation type.

Basement Features

What features does your basement have?

100% finished
Partially finished
Unfinished
Walkout
Crawlspace
Other

Machinery Location

Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)

Basement
Basement, but elevated
Garage
Garage, but elevated
Outside
Outside, but elevated
Other

Contents Location

Where is your personal property kept at this location?

Flood Vents

Does this home have flood vents?

Yes
No

Flood Insurance Policy

Do you have a flood insurance policy in place today?

Yes
No

Flood Policy PDF

If you have a PDF of your policy, please upload it for us. (This is optional, but it may allow us to apply a better rate)

Max. file size: 128 MB.

Claims

Have you been paid over $5,000 on any flood claims in the last 10 years?

Yes
No

Claims Description

Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.

Policy Cancellation

Is your policy being cancelled or non-renewed?

Yes
No

Policy Cancellation Description

Please tell us your insurer's reason for cancelling or non-renewing your policy.

Elevation Certificate

Do you have an elevation certificate for this property?

Yes
No

Elevation Certificate File

Please upload a copy of the elevation certificate to us.

Max. file size: 128 MB.

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)

Drop files here or

Accepted file types: jpg, gif, tiff, png, pdf, Max. file size: 128 MB, Max. files: 5.

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Consent*

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.

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High Hazard Flood Zone Insurance Form

Documents and Comments

Alice Romeo

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High Hazard Flood Zone Insurance Form

Documents and Comments

Alice Romeo

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RiskRevu^TM Newsletter