Flood Insurance Request Form

Date:

Name:

Date of Birth:

Address:

Mailing Address same as Physical Address:

Email:

Phone #:

Date Purchased:

Date Built:

Square Feet:

1 or 2 story:

Siding:

Roof Material:

Age of Roof:

Current Insurance:

Current Insurance Co. Name:

Renewal or Non-Renewal Date:

Any claims last 5 years:

Loss/Date/Amount:

Quote for loan closing:

Multiple structures on property:

Description and size:

Purchased within last year & prior owner had NFIP Policy:

Building under construction:

Building over water:

Occupancy percentage:

Additions or extensions:

Describe:

Substantial improvements since construction:

Non-profit entity:

Rental property:

Prior NFIP Policy lapsed:

Foundation:

Elevators:

Machinery & equipment elevated above 1st floor:

Heat & A/C unit on roof:

Flood Insurance Quote Form - Assurity Solutions Group LLC d/b/a John Galt Insurance