TEST Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.1234Property Address for Coverage *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePlease Enter Your Local County Name *Is your mailing address the same as this property? *YesNoPlease provide your mailing addressAddress Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContinue My Quote ►What's your reason for seeking flood insurance?" *Please select oneBuying or recently bought a new homeReplacing my existing policyRefinancing a loanNew flood map, lender now requires itJust want to have coverageOther (please specify in notes)When do you need the policy to start? *Is the property you are looking to insure under a Trust, LLC or other name that is not yours? *NoYesPlease enter the Trust Name, LLC Name or other name here. *Primary Policyholder's Name *FirstLastYour Phone Number * that mobile there Your Email Address *We will always send you an email of your quote so you have it in writing. Would you like us to call you when we have the quote ready? *Yes! Call me when you have my quote.No! Please just send an email.Please Enter Your BirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there anyone else that should be listed on this policy? *NoYesAdditional Policyholder's NameFirstLastAdditional Policyholders Email Address Additional Policyholders Phone NumberAdditional Policyholders BirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920↩ PreviousNext ►What type of property are you looking to insure? *Please select oneSingle FamilyTownhouseCondo UnitDuplexTriplexFourplexMobile Home / Manufactured HomeModular HomeHow is the building primarily used? *Please select oneAs my main residenceAs my secondary residenceI own it and rent it out to othersRenting: contents coverage only.Solely for business purposes (not as a residence)Is your property currently under construction or planned to be built? *NoYesFor the property under construction, please provide the following: Drag & Drop Files, Choose Files to Upload 1) A Google Maps link and the latitude and longitude coordinates of the property. 2) Photos of all external sides of the property, or architectural plans if available. 3)If you have an Elevation Certificate, please include that as well.Please enter your condo unit number or letter. *How many units are there in the entire building? *Please enter the total number in the building your unit is in. How many floors does your condo building have? *Please select the floor where your condo unit is located: *Please select oneBasement – “My condo unit is underground.”First Floor – “My condo unit is at ground level.”Second Floor or HigherWhat is the exact floor number of your condo unit? *You've Chose 'Mobile Home/Manufactured Home': Review the descriptions to confirm your choice.Mobile Home: “A mobile home is built on a chassis and can be moved. It’s prefabricated and transported to its location.” –//– Manufactured Home: is the same as a mobile home, built on a steel frame with wheels for mobility. –//– Modular Home: “A modular home is made in sections at a factory and assembled at a fixed site. It’s not designed to be moved after assembly.”Is the mobile home / manufactured home anchored to a permanent foundation? *YesNoHow is the mobile home secured? *Please select oneAnchored per manufacturer’s guidelinesAnchored to floodplain management standardsSecured with ties to ground anchorsNot anchored (uninsurable)Has the mobile home had its wheels and tires removed? *YesNoWhat is the serial number of the mobile home? *If unknown, enter ‘0000’ and you can provide it before finalizing the policy.You've Chose 'Modular Home': Review the descriptions to confirm your choice.Modular Home: “A modular home is made in sections at a factory and assembled at a fixed site. It’s not designed to be moved after assembly.” –//– Mobile Home: “A mobile home is built on a chassis and can be moved. It’s prefabricated and transported to its location.” –//– A Manufactured Home is the same as a mobile home, built on a steel frame with wheels for mobility.How much coverage do you need for the building itself? *Please select one$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$275,000$300,000$325,000$350,000$375,000$400,000$425,000$450,000$475,000$500,000More then $500,000How much coverage do you want for your personal belongings inside (like furniture, electronics, clothing)? *Please select one0$10,000$20,000$30,000$40,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$275,000$300,000$325,000$350,000$375,000$400,000$425,000$450,000$475,000$500,000More then $500,000Deductible *$5,000$10,000Do you need insurance for other structures on your property? *YesNoCoverage for Additional Structures? *Please select one$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$275,000$300,000$325,000$350,000$375,000$400,000$425,000$450,000$475,000$500,000More then $500,000If you desire lower coverage please put in the notes the amount you wanted.Contents Coverage for Additional Structures? *Please select one0$10,000$20,000$30,000$40,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$275,000$300,000$325,000$350,000$375,000$400,000$425,000$450,000$475,000$500,000More then $500,000↩ PreviousNext ► Has the property experienced flood damage? *Please select oneNoYESI don’t know but will ask Seller When did the flood loss occur? *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What was the total cost of damage, including deductible, contents, and building? *Have there been multiple flood losses on this property? *YesNoDid you file a claim? *YesNoWhat year was the building constructed? *What type of foundation does your building have? *Please select oneSlabCrawlspaceSplit LevelBasementElevated BuildingWhich description best fits your basement foundation? *Please select oneFully underground on all sidesWalkoutWhich description best fits your elevated foundation? *Please select oneElevated Open with no enclosureElevated with the area underneath partially enclosed.Elevated with only a garage underneath.Elevated with a garage and additional room underneathElevated with the area underneath completely enclosed.Which description best fits your split level foundation? *Please select oneSplit level fully or partially undergroundSplit level slab above groundWhich description best fits your crawlspace foundation? *Please select oneCrawlspace fully or partially undergroundCrawlspace Above groundHow many floors does the building have? *Please select one12345 or moreHow many floors above ground does the building have? (Do not include the basement.)What is the total square footage of the structure? *What material is the building's frame constructed from? *Please select oneWood FrameBrick or MasonryStuccoSteel FrameWhat type of garage does the property have? *Please select oneNo GarageAttached GarageDetached GarageHow many cars can your garage hold?Please select one12345 or moreDoes your property have any rooms with floor-to-ceiling wood paneling? *Please select oneNo, there is no wood paneling.Yes, one small room has wood paneling.Yes, one medium to large room has wood paneling.Yes, two or more rooms have wood paneling.What flood zone is your property located in? *Please select oneZone AEZone XZone VEZone AZone VZone AOZone AHIf you’re unsure about your flood zone, simply select Zone AE, and your flood nerd will verify your correct flood zone for you. This ensures you get accurate coverage without the guesswork.Additional InformationPlease share any other details or notes about your property that you think are important for your insurance coverage.I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business. *Yes I agree.PreviousLet’s Finish This ►►►
