Flood Coverage

Applicant Name: Best Time To Contact: Contact Person: Phone: Fax: E-mail Address: Property Address: City: State: -Select One- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip: Date of Construction: Amount of Building Coverage Requested: $ Amount of Contents Coverage Requested: $ Date Purchased Property: Is Property?: -Select One- Principal Residence Condominium Small Business In Course of Construction Owned by Government What is Building Occupancy?: -Select One- Single Family 2-4 Families Other Residential Non-residential What is Building Type?: -Select One- 1 Floor 2 Floors 3 Floors Split Level Townhouse Manufacture/Mobile Home Is the Garage?: Attached Detached What is Garage Used For?: Parking/Storage Other Describe, if any, the machinery or equipment stored: If There Is A Basement/Enclosure:   Are all four sides below grade?: Yes No Is Basement/Enclosure?: Finished Unfinished What is basement/enclosure used for?: What is contained in basement?: -Select One- Furnace Heat Pump Air Conditioner Hot Water Heater Oil Tank Elevator Equipment Cistern Describe any other attached machinery/equipment in basement: If The Building Is Elevated:   Is the area below elevated floor?: -Select One- On Piers Concrete Piers/Columns Concrete Shearwalls Solid Perimeter Walls Is area enclosed? : Yes No Is enclosed area greater than 300 square feet?: Yes No Area enclosed with: -Select One- Light Wood Lattice Insect Screening Breakaway Walls Solid Wood Walls Masonry Walls Does area have opening or breakout panels? : Yes No