| Personal
Information |
| *Name: |
|
| *Address: |
|
| *City: |
*State:
*Zip:
|
| Gender: |
Male
Female |
| *Daytime Phone Number: |
|
| Evening Phone Number: |
|
| *Email: |
|
| Best Time to Contact You: |
|
| Best Number to Contact You: |
|
| Property
Information |
| Township,
Boro, Community Name |
|
Street
address
(no PO Box) |
|
| Address
(cont.) |
|
| City |
|
| County/Parish |
|
| State |
|
| Zip
code |
|
Lot,
block, subdivision
(if known) |
|
| Building
and Contents |
| FIRM
zone |
|
| Building
occupancy |
|
| If
you answered "Non-residential" about building
occupancy, provide description of use |
|
| Check
all that apply |
Is the building located in a Unincorporated Area?
Is the building in the Coarse of Construction?
Is the building Government Owned?
Is the policy required for Disaster Assistance?
Does the Basement have Machinery and Equipment? |
| Building
type |
|
| If
you answered "Condominium" about building
type, select from drop down menu |
If Association, number of units |
| Foundation
type |
|
|
Note: Sub-Grade
means any area of the building, including any
sunken room or sunken portion of a room, having
its floor below ground level on all sides. The
policy provides only limited coverage in basements
and for the enclosed areas below elevated buildings.
|
| Garage
Information |
If attached or built-in:
Does Garage contain Machinery or Equipment?
Is Machinery and Equipment elevated to the
reference floor level?
Is Garage used for other than parking? |
| Property
construction date (mm/dd/yyyy) |
|
| Is
building principle residence? |
|
| During
the period of ownership, has property owner received
2 or more flood insurance claim payments or flood
disaster relief payments (including loans and grants)
of $1,000 or more? |
|
| Contents
location |
|
| Lowest
floor elevation (if known) |
|
| Base
flood elevation (if known) |
|
| Type
of Insurance |
| Policy
Type |
|
| Building
replacement cost |
$
|
| Coverage
for Building |
$
|
| Coverage
for Building Contents |
$
|
|
| Fields marked with * are required. |
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