What is your first name? ** What is your first name? *
What is your last name? ** What is your last name? *
What is your preferred phone number? ** What is your preferred phone number? *
What is your email address? ** What is your email address? *
What is your occupation? What is your occupation?
What is the name of your employer? What is the name of your employer?
What is your date of birth? ** What is your date of birth? *
MM slash DD slash YYYY
What is your marital status? ** What is your marital status? *
Single Married Domestic Partnership Engaged Divorced Widowed
What is your spouse's full name? What is your spouse's full name?
What is your partner's full name? What is your partner's full name?
What is your fiancé's full name? What is your fiancé's full name?
Please enter their occupation. Please enter their occupation.
Please enter their employer. Please enter their employer.
Please enter their date of birth. Please enter their date of birth.
MM slash DD slash YYYY
Please enter the address for the property you would like a flood insurance proposal for. ** Please enter the address for the property you would like a flood insurance proposal for. *
Will this address also be used as your mailing address? Will this address also be used as your mailing address?
What is your mailing address? ** What is your mailing address? *
Are you in the process of purchasing this property? ** Are you in the process of purchasing this property? *
What is the closing date? ** What is the closing date? *
MM slash DD slash YYYY
When do you want this coverage to start? ** When do you want this coverage to start? *
MM slash DD slash YYYY
What type of building is on this property? ** What type of building is on this property? *
Single Family Home Residential Manufactured/Mobile Home Residential Condo/Coop Unit Two-to-Four Family Building Other Residential Building Other Residential Unit
Please enter the manufactured/mobile home's identification number below. Please enter the manufactured/mobile home's identification number below.
Please choose the best description of the building(s)/unit(s) you are seeking coverage for below? * (Select all that apply)* Please choose the best description of the building(s)/unit(s) you are seeking coverage for below? * (Select all that apply)
On which floor is the unit located? On which floor is the unit located?
Please choose the best description of the building you are seeking coverage for below? ** Please choose the best description of the building you are seeking coverage for below? *
What is the total number of units in the building? What is the total number of units in the building?
Select the occupancy of this property? ** Select the occupancy of this property? *
Primary residence Rented to others Secondary residence Other
Please enter the occupancy of this building. Please enter the occupancy of this building.
Is this building currently under construction? Is this building currently under construction?
When did the construction begin? ** When did the construction begin? *
MM slash DD slash YYYY
When will the construction end? When will the construction end?
MM slash DD slash YYYY
Are you planning any major renovations to this building? Are you planning any major renovations to this building?
Please tell us more about your renovation plans. Please tell us more about your renovation plans.
Please provide a brief overview of the renovation project. (i.e. Kitchen remodel, etc.) Please provide a brief overview of the renovation project. (i.e. Kitchen remodel, etc.)
Is the address of your primary home the same as your mailing address? ** Is the address of your primary home the same as your mailing address? *
What is the address of your primary residence? ** What is the address of your primary residence? *
Will there be a mortgage? Will there be a mortgage?
What is the name of the bank providing the mortgage? What is the name of the bank providing the mortgage?
Who is your contact at the bank? Who is your contact at the bank?
What is the phone number for your contact at the bank? What is the phone number for your contact at the bank?
What is the email address for your contact at the bank? What is the email address for your contact at the bank?
Will the insurance premium be escrowed? Will the insurance premium be escrowed?
Is there a mortgage? Is there a mortgage?
Please enter the bank name, if convenient. Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. Please enter the bank address, if convenient.
Please enter the loan number, if convenient. Please enter the loan number, if convenient.
Is the insurance premium being escrowed? Is the insurance premium being escrowed?
Is there a second mortgage or home equity loan? Is there a second mortgage or home equity loan?
Please enter the bank name for the second mortgage or home equity loan, if convenient. (Ex. Bank of America NA, ISAOA ATIMA) Please enter the bank name for the second mortgage or home equity loan, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address for the second mortgage or home equity loan, if convenient. Please enter the bank address for the second mortgage or home equity loan, if convenient.
Please enter the loan number for the second mortgage or home equity loan, if convenient. Please enter the loan number for the second mortgage or home equity loan, if convenient.
Is the insurance premium being escrowed for the second mortgage or home equity loan? Is the insurance premium being escrowed for the second mortgage or home equity loan?
Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?** Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?*
Legal Entity Information What is the name of the legal entity? What is the name of the legal entity?
What type of legal entity is it? What type of legal entity is it?
Limited Liability Company (LLC) Trust Limited Liability Partnership (LLP) Family Limited Partnership (FLP) Other
Please enter the type of legal entity: Please enter the type of legal entity:
What is the mailing address for the legal entity? What is the mailing address for the legal entity?
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...) Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you. Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
What is the purpose or intent of the entity? What is the purpose or intent of the entity?
Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business? Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business?
Please provide details about the income generation and business conducted by this entity. Please provide details about the income generation and business conducted by this entity.
Does the entity generate income in any other ways? Does the entity generate income in any other ways?
Does the entity own any other real estate, vehicles, watercraft or other tangible assets? Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...) Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees? Does the entity have any employees?
Please list the name and occupation for each of the employees: Please list the name and occupation for each of the employees:
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...) Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies? Does the entity maintain any other insurance policies?
Please provide the insurance company name(s), coverage type and coverage limits for the other policies. Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Construction Information What year was the building built? (YYYY) What year was the building built? (YYYY)
Has the building been substantially improved since it was built? (Over 50% of the market value was spent to renovate) Has the building been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
What is the approximate date this building was substantially improved? What is the approximate date this building was substantially improved?
What is the approximate square footage of the building? What is the approximate square footage of the building?
How many floors does this building have? (Not including a basement/enclosed area/attic) How many floors does this building have? (Not including a basement/enclosed area/attic)
Does the building have any elevators? Does the building have any elevators?
How many elevators does the building have? How many elevators does the building have?
What is the primary material used in the construction of this property? What is the primary material used in the construction of this property?
-- please select -- Brick Masonry Wood Other
Please provide a description of the primary material used in the construction of this building. Please provide a description of the primary material used in the construction of this building.
Are there any other buildings on the property that you want flood coverage for? (i.e. pool houses, detached garage, etc...) Are there any other buildings on the property that you want flood coverage for? (i.e. pool houses, detached garage, etc...)
Please tell us about the other buildings for which you would like Flood coverage. Please tell us about the other buildings for which you would like Flood coverage.
Please select this building's foundation type: ** Please select this building's foundation type: *
Slab on Grade (Non-Elevated) Basement (Non-Elevated) Crawlspace (Elevated or Non-Elevated Sub-Grade Crawlspace) Elevated Without Enclosure On Posts, Piles, or Piers Elevated With Enclosures On Posts, Piles or Piers Elevated With Enclosures Not On Posts, Piles or Piers (Solid Foundation Walls) Other
Please describe the foundation type. ** Please describe the foundation type. *
Is the enclosure/crawlspace constructed with proper flood openings or engineered openings?* Is the enclosure/crawlspace constructed with proper flood openings or engineered openings?
What is the total number of flood openings? ** What is the total number of flood openings? *
What is the total area of all permanent openings? (In square inches) ** What is the total area of all permanent openings? (In square inches) *
What is the square footage of the enclosed area? ** What is the square footage of the enclosed area? *
Is the building over water? Is the building over water?
Is the building properly flood-proofed? Is the building properly flood-proofed?
Where is the machinery that services this building located? (Air conditioning, Furnace, Boiler, etc...) Where is the machinery that services this building located? (Air conditioning, Furnace, Boiler, etc...)
Please check the boxes next to the words that best describe your basement. (Select all that apply) Please check the boxes next to the words that best describe your basement. (Select all that apply)
Please provide a brief description of this building's basement. Please provide a brief description of this building's basement.
Where is your personal property kept at this location? Where is your personal property kept at this location?
Ground level and above Basement and above Elevated floor and above Other
Does the building have any elevators? Does the building have any elevators?
How many elevators does the building have? How many elevators does the building have?
Do you have a flood insurance policy in place today? Do you have a flood insurance policy in place today?
Do you have a prior NFIP flood insurance policy that lapsed for a valid reason? Do you have a prior NFIP flood insurance policy that lapsed for a valid reason?
Please upload a copy of the flood insurance policy. (Optional) Please upload a copy of the flood insurance policy. (Optional)
Have you been paid over $5,000 on any flood claims in the last 10 years? Have you been paid over $5,000 on any flood claims in the last 10 years?
Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened. Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.
Is your policy being cancelled or non-renewed? Is your policy being cancelled or non-renewed?
Please tell us your insurer's reason for cancelling or non-renewing your policy. Please tell us your insurer's reason for cancelling or non-renewing your policy.
Do you have an elevation certificate for this property? Do you have an elevation certificate for this property?
Please upload a copy of the elevation certificate. Please upload a copy of the elevation certificate.
Documents and Comments Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, elevation certificate, etc...) Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, elevation certificate, etc...)
Please enter any additional remarks in the space below. Please enter any additional remarks in the space below.
How did you hear about us? How did you hear about us?
Current customer Referred by... Google search Agency's website Email newsletter Facebook Instagram Twitter Other
Please share who referred you to us. Please share who referred you to us.
Please share what you typed into Google. Please share what you typed into Google.
Please share how you heard about us. Please share how you heard about us.
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.
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