Fill Out the Form To Request a Flood Insurance Quote Form "*" indicates required fields Name of AgentName Address Email PhoneIs the Insured a Business Yes No Insured Information Name* Address* Client Name and Property AddressName Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property DescriptionMailing Address Same as Property Address Yes No Mailing Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Waiting PeriodStandard 30 day +Loan Closing No WaitRenewal ConversionEffective Date MM slash DD slash YYYY Is there a current NFIP policy on this building Yes No Building InfoBuilding PurposeResidentialNon ResidentialMixed UseBuilding OccupancySingle Family HomeRESIDENTIAL MANUFACTURED/MOBILE HOMERESIDENTIAL UNIT2-4 FAMILY BUILDINGOTHER RESIDENTIAL BUILDINGRESIDENTIAL CONDOMINIUM BUILDINGBuilding DescriptionENTIRE APARTMENT BUILDINGAPARTMENT UNITENITRE COOPERATIVE BUILDINGCOOPERATIVE UNITDETACHED GUEST HOUSEMAIN DWELLINGENTIRE RESIDENTIAL CONDOMINIUM BUILDINGRESIDENTIAL CONDOMINIUM UNIT- IN RESIDENTIAL BUILDINGRESIDENTIAL CONDOMINIUM UNIT – IN NON RESIDENTIAL BUILDINGOTHER DWELLING TYPEOTHER Building Under Construction Yes No Walled and Roof Yes No Building Partial or entirely over water Yes No Percentage of the year living in the house: 80%+ 51-79% 50% or less Include coverage for additions or extensionsNoneBuilding is Addition/ExtensionExcluded Additions/ExtensionsIncludes Additions/ExtensionsIs the Insured a Condominium Yes No Original construction Date MM slash DD slash YYYY Has the building been substantially Improved Yes No Is the building a rental property Yes No Is the insured as tenant Yes No Is the insured a non-profit entity Yes No Is the policy being forced place by the lender Yes No Is the building located on or leased Federal Property Yes No Is the insured a Small Business with less than 100 employees Yes No Did the applicant have a prior NFIP policy for the building that received a newly mapped discount and lapsed Yes No Building Design InformationFoundation typeSlab on gradeBasement (Non-elevated)Crawlspace (elevated or non-elevated, sub-grade crawlspaceElevate without enclosure on posts, piles or piersElevated with enclosure on posts, piles or piersElevated with enclosure not on post, piles or piers (Solid foundation walls)Construction TypeFrameMasonryOtherSquare Footage Number of floors excluding enclosure, crawlspace or basement Number of detached structures Elevator(s) servicing the building Yes No Is there machinery and equipment elevated above the building’s first floor? Yes No Elevation certificate Yes No Coverage InformationTotal Building Coverage Total contents Coverage Mortgagee Clause:Lender Name Lender Address ISAOA ATIMA Bill to Lender Yes No Loan Number Lender TypeFirst MortgageeSecond MortgageeLoss PayeeDisaster AgencyCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Follow the link below to visit or return to Colyott & Watson Insurance Group Colyott & Watson
