Step 1 of 3 33% Requesting AgencyRequesting Agent First Last Agent PhoneAgent Email Insured A Business? If yes complete business name.NoYesName First Last Additional Name First Last Business NamePhone NumberEmail Address Property Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property Address same as Mailing AddressYesNoIf no please complete the mailing address.Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are There Multiple Structures on the property?NoYesNot SureFlood Zone Determination or Elevation Certificate Available?No DocumentationFlood Zone DeterminationElevation CertificateRequested Effective Date Date Format: MM slash DD slash YYYY Lender Required CoverageYesNoIs the Building a Condominium?Other (Not a Condo)Single Condo UnitResidential CondominiumCommericial CondominiumOriginal construction Date* Date Format: MM slash DD slash YYYY Is the insured a tenant?NoYesIs the prospect a non-profit entityNoYesIs the building to be a rental property?*NoYesProperty Purchase Date or Anticipated Purchase Date Date Format: MM slash DD slash YYYY Is Insurance Required for Disaster AssistanceNoYesBuilding PurposeResidentialNon-residentialMixed UseBuilding OccupancySingle Family2-4 FamilyOther ResidentialOther non-ResidentialNon-residential - BusinessBuilding UsageIn most cases, this will be the main house but there are a number of possibilities. Just enter how it is currently being used.Building Under ConstructionNoYes Occupancy Percentage80% or MoreBetween 51 - 79%50% or LessGarage AttachedYesNoBasement/Enclosure/Crawlspace*NoneBasementEnclosureCrawlspaceSubgrade CrawlspaceBasement Finished* No Yes Appliances, Washer/Dryer, or Freezer No Yes Are any of these contained in the basement?Number of Floors Including Basement/Crawlspace/Enclosure*One FloorTwo FloorsThree or More FloorsSplit LevelBuilding Coverage RequestedPlease enter a number from 0 to 500000.Contents Coverage RequestedPlease enter a number from 0 to 500000.CommentsMortgagee Clause Pages: 1 2
