Business Flood Insurance Quote Request

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BUSINESS FLOOD INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain a Business Flood Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your business name?	Business Name
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Home
What is your telephone number?	Business
What is your fax number?	Fax
What is your email address?	Email
Building & Property Information
What is the property address?	Property Street
	Property City
	Property State
	Property Zip
What is the occupancy type?	Occupancy Type
What is the building type?	Building Type
What year was it built?	Year Built
What is the flood map zone number?	Flood Map Zone Number
What is the total square footage of the building?	Total Square Footage of Building
How many units are in the building?	Units
What is the garage description?	Garage Description
How many stories is it?	Stories
What is the construction type?	Construction Type
What is the foundation type?	Foundation Type
What is the nature of sub-soil?	Nature of Sub-Soil
What is the topography?	Topography?
What type roof covering?
Is the roof updated?	Roof Updated	Yes No
If yes, what year?	Year Roof Updated
Is there any erosion in the area?	Erosion
Is there any below ground parking?	Below Ground Parking	Yes No
Is there any soft first story or tuck under parking?	Soft First Story or Tuck Under Parking	Yes No
What is the distance of fire protection?
Is the business in a brush area?	Brush	Yes No
If yes, has the brush been cleared by 250 feet from all around the building?	Brush Cleared by 250 Feet	Yes No
Are there smoke detectors at this location?	Smoke Detectors	Yes No
Are there fire extinguishers?	Fire Extinguishers	Yes No
Are there circuit breakers?	Circuit Breakers	Yes No
Is the electrical updated?	Electrical Update
How old is the heating/ air conditioning?	Age of Heating/ Air Conditioning
What is the energy source?	Energy Source
Has the plumbing been updated?	Plumbing Updated	Yes No
If yes, what year was the plumbing updated?	Year Plumbing Update
Is the plumbing copper?	Copper Plumbing
Does the building have interior automatic fire sprinklers?	Automatic Fire Sprinklers
Is there a fire alarm?	Fire Alarm
Has the building been retrofitted or bolted?	Retrofitted or Bolted
Claims Information
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Coverage
What is the building coverage requested?	Building Coverage
What is the other structures coverage requested?	Other Structures Coverage
What is the contents property coverage requested?	Contents Property Coverage
What is the loss of use coverage requested?	Loss of Use Coverage
Are there any questions, comments or additional coverage required?	Questions, Comments or Additional Coverage

Best Time to Contact You
Please let us know the best time to call and discuss your quote.	Morning Afternoon Evening Anytime	Or specify other:


	The Wayne Oakland Agency PO Box 3158 \| Oak Brook, IL 60522-3158 Phone 248-649-6006 Fax 630-402-6390

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