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Flood Quote Submission starklogic 2017-02-07T15:52:45-06:00

Flood Quote Submission

Please complete the following form to receive a flood quote. After completion our underwriter will get back with you.

If you are human, leave this field blank.

Flood Quote

Agency Information

Agency Name *

Agency Code *

Email *

Please put the information for the agent that is submitting the quote request

Agent First Name *

Please put the information for the agent that is submitting the quote request

Agent Last Name *

Please put the information for the agent that is submitting the quote request

Agency Phone Number *

Insured & Property Information

Is NFIP/FEMA required?

Yes

No

Private flood an option?

Yes

No

Will this be under a business name? *

Or Trust

Yes

No

Insured's Business Name:

Insured's First Name *

Insured's Last Name *

Add Additional Named Insured? *

Yes

No

Additional Insured - First Name *

Additional Insured - Last Name *

Physical Address of Property *

Country

City

State

Zip code

Legal Description

Parcel ID

Mailing address same? *

Yes

No

Mailing Address:

Country

City

State

Zip code

Property Purchase Date: *

Are there multiple or any detached structures on the property? *

Yes

No

Number of Detached Structures *

Please advise what detached structures are on the property: *

Please describe the building for which the quote is being requested. *

Has the structure had a previous flood loss? *

Yes

No

Date of Loss: *

Amount of Loss: *

When does this need to be effective? *

Standard 30 days (Not for loan closing)

Loan closing requirement (No wait)

Renewal (Match current NFIP expiration date)

Map Revision

When was the area remapped? *

Requested Effective Date: *

For Renewal, Current Carrier *

For Renewal, Current Policy Number *

For Renewal, When did the insured start the current policy? *

For Renewal, Current policy expiration date: *

Please attach the current dec page *

Is Insurance Required for disaster assistance? *

Yes

No

Is the building the insured's primary residence? *

Yes

No

What is the building type? *

Manufactured Home

Residential

Non-Residential

Non-Residential Business

Make for Manufactured Home: *

Model for Manufactured Home: *

Serial Number for Manufactured Home: *

Length & Width for Manufactured Home: *

Is the manufactured home anchored to a permanent foundation? *

Yes

No

Is the manufactured home set in a mobile home park? *

Yes

No

Building Occupancy? *

Non-Residential

Single Family Home

Residential Manufactured Home/Mobile Home

Residential Unit

2-4 Family Building

Other Residential Building

Residential Condominium Building

Building Occupancy? *

Building Description? *

Main Dwelling

Detached Guest House

Other (Residential)

Other (Non-Residential)

Describe the building that is to be insured: *

Is the building under construction? *

Yes

No

Walled & Roofed? *

Yes

No

Is the building partially or entirely over water? *

Not over water

Entirely over water

Partially over water

What percentage of the year will the INSURED live in the building? *

N/A for Commercial

50% or Less

Between 51% - 79%

80% or More

Have there been any additions or extensions to the structure? *

Yes

No

Year Built? *

Is the property a condominium unit? *

Yes

No

Has the building been substantially improved since the original date of construction? *

Yes

No

When was the building been substantially improved? *

Is the building a rental? *

Yes

No

Is the insured a tenant? *

Yes

No

Does the tenant have an insurable interest in the building coverage? *

Yes

No

Is the building for a non profit? *

Yes

No

Is Building Located on Leased Federal Property? *

Yes

No

Is this for a small business with less than 100 employees? *

Yes

No

Does the applicant have a prior NFIP Policy? *

Yes

No

Foundation Type *

Basement

Enclosure

Crawlspace

Slab

Enclosure or Crawlspace Square Footage? *

Construction Type? *

Masonry

Wood Frame

Steel Frame

Concrete

Mobile/Manufactured Home

Square Footage of Building *

How many floors does the building have? (Excluding basement) *

Number of units within the building? *

Elevator(s) servicing the building? *

Yes

No

Number of elevators? *

Is the machinery and equipment elevated above the building’s first floor?

Yes

No

Building's estimated replacement cost? (Impacts quoted premium) *

Amount of Coverage Requested for the Building *

Will there be any contents needing insurance coverage? *

Yes

No

For contents needing insurance, please enter coverage amount *

Requested Building Deductible *

$1,000

$1,250

$2,000

$3,000

$4,000

$5,000

$10,000

Requested Contents Deductible *

$1,000

$1,250

$2,000

$3,000

$4,000

$5,000

$10,000

Is the property mixed use? *

Yes

No

If mixed use, what is percentage? *

Is the building for a House of Worship? *

Yes

No

Is the building for an agricultural structure? *

Yes

No

Is the basement finished or unfinished? *

Finished

Unfinished

N/A

Please provide any supporting documentation you may have, including: flood zone determinations and elevation certificates.

Document 2

Document 3

Document 4

Any additional Questions or Comments?

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