FLOOD INFORMATION SHEET

Please FAX completed form to Dave at (201) 652-0721

 

Effective Date: _______________                               Today’s Date: _________________

 

Name(s) as it appears on deed or lease: ___________________________________________

 

                                                           ___________________________________________

 

Owner Date of Birth: ______________                    Co-Owner Date of Birth: _______________

 

Owner Social Security #: ___________                    Co-Owner Social Security #: ____________

 

Owner Occupation: ________________                  Co-Owner Occupation: ________________

 

Mailing Address: _____________________________________________________________

 

Location Address (if different): __________________________________________________

 

Telephone Number(s): HOME ____________ CELL ____________ WORK ______________

 

Mortgage Company: __________________________________________________________

 

                               __________________________________________________________

 

Mortgage Amount: $ ___________________  Bill to: Insured or Mortgagee (Please Circle One)

 

 

New Purchase: YES __               If Yes, Market Value: $ _________________

 

                         NO  __   If No, Prior Carrier Name & Policy # __________________________

 

                                                                                                  __________________________

 

                                       Dwelling Limit on Prior Policy: $ _______________

 

                                       Liability Limit on Prior Policy: $ ________________

 

                                       Did Your Prior Policy: Cancel __        Non-Renew __

 

                                       If So, Please State Reason Why: ______________________________

 

                                       Date Coverage Ended or Will Cease: __________________________

 

 

Residence:   Primary __     Seasonal __               Occupancy:  Owner/Tenant ___        Tenant ___

 

# Living Units: ____________                           Year Built: ________

 

Construction Type:   Frame __               Masonry __

 

Year of Updates:   Plumbing _____       Electric _____              Heat _____      Roof _____

 

Heating Type:   GAS __    OIL __         Sump Pump:   YES ___   NO ___

 

If OIL heating, where is tank located?   ABOVE GROUND __     BELOW GROUND __

 

Number of Stories:  1    1.5    2    2.5     3     (Please Circle One)

 

Square Footage: _________     Alarm Type:  Local __   Direct __   Central __

 

Total Room Count:  Bedrooms ____    Full Bathrooms ____    Half Baths ______

 

Basement:    Finished ___   Partially Finished ___    Unfinished ___

 

Garage:  Attached ___    Detached ___    Number of Cars: _______

 

Any Business Conducted on Premises:               YES __                 NO __

 

Located Within 4 Miles of Ocean or Bay:           YES __     NO __

 

How did you hear of our Agency? __________________________________________________

 

WE WILL NEED TO ORDER AN INSURANCE SCORE FOR QUOTING.  PLEASE INITIAL WHERE INDICATED FOR PERMISSION TO ORDER SAID DOCUMENT.

 

X ______        

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PLEASE SELECT ONE (1) OF THE FOLLOWING EIGHT (8) DIAGRAMS AS THE MODEL THAT MOST CLOSELY RESEMBLES THE PROPERTY TO BE INSURED:  MODEL # _____.

 

   

Diagram 1: Distinguishing Feature - The            Diagram 2: Distinguishing Feature - The

bottom floor is at or above ground level            bottom floor (basement or underground

(grade) on at least one side.                              garage) is below ground level (grade) on

                                                                        all sides.  Buildings constructed above

                                                                        crawl spaces that are below grade on all

                                                                        sides should also use this diagram.

 

 

Diagram 3: Distinguishing Feature - The        Diagram 4: Distinguishing Feature - The

bottom floor (excluding garage) is at or         bottom floor (basement or underground

above ground level (grade) on at least           garage) is below ground level (grade) on

one side.                                                       all sides.  Buildings constructed above

                                                                    crawl spaces that are below grade on all

                                                                    sides should also use this diagram.

 

 

Diagram 5: Distinguishing Feature - For all         Diagram 6: Distinguishing Feature: For all

zones, the area below the elevated floor             zones, the area below the elevated floor is

is open, with no obstruction to flow of               enclosed, either partially or fully. In A zones,

flood waters (open lattice work and/or              the partially or fully enclosed area below the

readily removable insect screening is                  elevated floor is with or without openings

permissible).                                                      present in the walls of the enclosure.

                                                                         Indicate information about openings in

                                                                         Section C, Building Elevation Information

                                                                         (Survey Required).

 

Diagram 7: Distinguishing Feature - For        Diagram 8: Distinguishing Feature - For all

all zones, the area below the elevated           zones, the area below the first floor is

floor is enclosed, either partially or fully.        enclosed by solid or partial perimeter walls.

In A Zones, the partially or fully                     In all A Zones, the crawl space is with or

enclosed area below the elevated floor          without openings present in the walls of the

is with or without openings present in            crawl space.  Indicate information about the

Section C, Building Elevation                       openings in Section C, Building Elevation

Information (Survey Required).                     Information (Survey Required).