Flood Insurance Request Form

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. 

I have read and agree with the above disclaimer (It is mandatory to check box before request can be sent)
Information

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.
Named Insured:
Address:
City:
State:
Zip:
Day Phone:    
Beeper:   
Eve. Phone:
Cell Phone:
E-mail Address:
Best Time To Contact:   AM   PM
Method of contact: Day Phone   Eve. Phone  Beeper
Cell   Email

Current Policy Information
Agent:
Insurance Company:
Policy Number:
Policy Expiration Date:

Mortgagee/Loss payee (Name and address)
Name:
Email:
Address:
City:       
State:
Zip:
Loan #:
Payor:
If "Other", specify:

Dwelling Information
# of Stories:
Construction:
If "Other", specify:
Additional Info:
Property Secondary Residence Yes   No
Is Property Occupied by: Owner   Tenant
Tenant Content: Yes   No
Type of Roof:
If "Other", specify:
Roof Covering:
If "Other", specify:
Roof Sheathing Attachment:
Garage:
Openings: (sliding glass doors: exits to porch, patio or exterior of dwelling)
Attached Porches/Carports:
Secondary Water Resistance: Yes   No
If yes, Which Type Exterior   Interior
Foundation Type:
Roof Tie Down Straps/Clips? Yes   No
Gable ends properly Braced? Yes   No
Reinforced Masonry Roof? Yes   No
Garage Door SSTD 12 or Dade County Approved? Yes   No
If no, is it braced with approved system? Yes   No
Amount of Insurance Requested on Dwelling: $(Replacement Cost, not Market Value)

Amount of Coverage
Amount Requested - Building: $
Amount Requested - Contents: $ (INC Additions & alterations) Limited to 50% of Building
Amount Requested - Other: $
Underwriting Information
100% Replacement Cost - Building: $  (N/A to Mobile Homes)
Actual Cash Value - Building: $ 
Actual Cash Value - Contents: $ 
This building was constructed: year
Total Area of Building (sq feet):
Flood Insurance Carrier: (Flood Policy mandatory in zones A & V)
Flood policy #:
Flood Zone:
Is there unrepaired Physical Damage to the Property? Yes   No
Is there losses in the last 2 years? Yes   No  (If yes, indicate in the comments box.)
Homeowners/Fire Insurance Carrier:
Homeowners/Fire Policy #:
Insuring Limit on HO Policy (if known):

Additional Comments

   

 
   
 

Copyright © 2002,  Fairchild, Addison & McKone Insurance, Inc.  All rights reserved.
No portion of this site may be reproduced in any manner without the prior written consent of FAHINS.
Site Created and maintained by FAIA Web Services