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
Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
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
What is your telephone number?
Home
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
Select
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Washington DC
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
Property Zip
What is the occupancy type?
Occupancy Type
Select
Owner
Tenant
Vacant
Owner & Tenant
What is the building type?
Building Type
Select
House
Condo - Contents
Townhome
Apartment Building
Office Building
Condo Assoc Complex
High Rise Building
Manufacturing Building
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
Select
No Carport - Garage
Car Carport - Attached
Car Carport - Detached
Garage - Attached
Garage - Detached
Tuck Under Parking
Above Ground Parking
Below Ground Parking
Parking Lot
Street Parking
How many stories is it?
Stories
Select
1
2
What is the construction type?
Construction Type
Select
Brick
Stone
Frame
Masonry
Superior
Log Cabin
Frame-Stucco
Masonry Veneer
What is the foundation type?
Foundation Type
Select
Flat Slab-Poured
Reinforced Concrete
Piers
Wood
Stilts
Posts-Pilings
Basement
Masonry
Rubble Stone
Non-Reinforced Concrete
Craw Space-Concrete
Perimeter
Craw Space-Wood Perimeter
What is the nature of sub-soil?
Nature of Sub-Soil
Select
Sand
Clay
Rock
Marsh
Filled Land
Unconsolidated Ground
Natural Consolidated
Ground
What is the topography?
Topography?
Select
Flat
Cliff
Terraced
Steep Hill
Gentle Hillside
Under 100ft to Water
Hillside Over 30 Degrees
What type roof covering?
Select
Architectural shingles
Asphalt/Fiberglass
shingles
Built-up/Tar and gravel
Clay tile
Concrete tile
Corrugated steel
Mineral fiber shakes
Mission Tile
Rock roof
Roll roofing
Rubber roof
Slate
Tin
Wood fiber shingles
Wood shake
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?
Select
1000
ft or less to hydrant & 5 mi or less to fire station
Over
1000 ft to hydrant & 5 MI or less to fire station
Over
5 & up to 10 MI to fire station
Over 10 MI to fire
station
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
Select
Yes, Recently Updated
No
How old is the heating/ air conditioning?
Age of Heating/ Air Conditioning
What is the energy source?
Energy Source
Select
Gas
Electrical
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
Select
None
Partial
Full
Is there a fire alarm?
Fire Alarm
Select
None
Local
Has the building been retrofitted or bolted?
Retrofitted or Bolted
Select
No, Building is Not
Bolted
Yes,
Recently Bolted or Retrofitted for EQ
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?
Select
20th Century
21st Century Casualty
AAA
AEGIS
AETNA
A G Edwards
AIG
Alliance
Allied
Allstate
American Family Insurance
American Manufacturers
Mutual
American National General
Amica Mutual
Blue Cross
Calfarm
Charter Insurance
CIGNA
Civil Service Employees
Clarendon National
CNA
Colonial Penn
Company Not Listed
Continental
Country Companies
Dairyland
Don't know name
Electric
Farm Bureau Insurance
Farmers
Farmers Union
Fidelity Guaranty
Fireman's Fund
First General
GEICO Casualty Co.
General Accident
Grange Ins Assn
Guaranty National
Hanover
Hartford
Horace Mann
John Hancock
Kemper
Liberty Mutual
Lumbermans Mutual
Metropolitan Insurance
Midwest Security
Millers Mutual Fire
Mutual of Omaha
Mutual of New York
National Farm Bureau
National General
Nationwide
New York Life
Northwestern Pacific
Pennsylvania General
Progressive
Providian
Prudential
Rural Insurance
SAFECO
Sentry
Shelter
State Farm
Travelers
Unigard
USAA
Viking
Workmens
Company Not Listed
Don't know name
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