Flood Insurance About You * Last  Name * First Name * MiddleName * Email * Email (retype) * Street Address * City Select State Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming * * Zip Ext. * Phone (Day) * Phone (Evening) Fax Your Flood Insurance Information Is this insurance quote for Homeowners Renters If this insurance quote is for Homeowners: Year Purchased Purchase Price Loan Amount If this insurance quote is for Renters: Monthly Rent Do you currently have flood insurance? Yes No If you answered 'yes' to having flood insurance: When does your current policy expire? (mmddyyyy) Who are you currently insured with? How much is your home insured for? Coverage Amount? Content Coverage Desired? Approximate Interior Square Footage Approximate Year Built * Is your home located within 5 miles of a fire station? Yes No Is your home susceptible to flooding or high water? Yes No * Is your home built on a hillside? Yes No Is your area prone to landslides and/or sinkholes? Yes No Have you experienced any losses or filed any claims within the last 5 years? Yes No * How many rooms? 5 5 1/2 6 6 1/2 7 7 1/2 8 8 1/2 9 9 1/2 10 10 1/2 11 11 1/2 12 12 1/2 13 13 1/2 14 14 1/2 15 Number of stories? 1 2 3 4 5 6 Over 6 Flood Zone A A1-30/AE AH AO A99 V V1-30/VE B,C, & X D Not Sure * Who lives in this residence? Owner Renter Under Construction Vacant How many living in the residence? 1 2 3 4 5+ What part of the year is the home occupied? Year Round Seasonal Never Do you have a basement? No Basement Unfinished Partly Finished Fully Finished Slab What part of the year is the home occupied? Year Round Seasonal Never Do you have a pool? No Above Ground Below Ground Other Do you have a garage? No Garage Carport Attached One Car Attached Two Car Attached Three Car Unattached One Car Unattached Two Car Unattached Three Car How many bedrooms? 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5+ How many bathrooms? 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5+ Type of exterior wall Adobe Aluminum/Vinyl Siding Asphalt Brick Veneer Cement Fiber Clap Board Concrete Block Log Siding Logs Mineral Fiber Painted Masonry Precast Concrete Precast Stone Slump Block Split Block Solid Brick Solid Stone Stone Veneer Stucco on Frame Stucco on Masonry Wood Shakes Wood Siding Other / Not Sure How many fireplaces? 1 2 3 4 5+ Age of Roof? 1 year old 2 years old 3 years old 4 years old 5 years old 6 - 10 years old 10 - 15 years old 15 - 20 years old 20 -25 years old 25 - 30 years old 30+ years old Type of roof Architectural Shingles Asphalt or Fiberglass Shingles Built-Up/Tar and Gravel Clay Tile Concrete Tile Corrugated Steel Mineral Fiber Shakes Mission Tile Rock Roof Roll Roof Rubber Roof Slate Tin Wood Fiber Shingles Wood Shake Other / Not Sure Rate your own credit Excellent Minor problems Bad Horrible Type of foundation Crawl Space Piers/Pilings/Stilts Slab on Grade Walkout Basement Wood Foundation Basement Unfinished Basement Other / Not Sure Details Any Comments / Questions?     Health Insurance Check List Auto Insurance Check List Home Owner's List FAQ Rate Your Insurance Company Career Opporunitity   Contact Us  |  FAQ |  About Us  |  Privacy Policies  |  Affiliate program Copyright © Insureitsmart.com, 2007. All Rights Reserved