Social Security Number
Please SelectSingle Occupancy2 to 4 FamilyOther ResidentialNon-Residential
Has property incurred 2 or more losses?
Total Building Coverage
Total Contents Coverage
Please SelectOne FloorSplit LevelTwo FloorsThree or more floorsTownhouse/Row HouseManufactured Home
Construction Date (MM/DD/YYYY)
Number of units in building
Basement / Enclosure of Crawl Space:
Please SelectNoneBasementEnclosure or Crawl Space
Does enclosure or crawl space area have compliant venting?
Is the lowest level a finished area?
Is machinery and/or equipment located on the lowest level?
Is the building elevated?
Lowest floor which includes living area, is off the ground by means of:
Please SelectPilesPostsPiersColumnsSolid Perimeter WallsParallel WallsConcrete WallsOther
Lowest level used for:
Square footage of lowest level:
Please SelectSolid PerimeterBreakawayLatticeOther
Please SelectLowest Floor Only – Above ground levelLowest floor above ground level & higher floorsAbove ground by one or more floors
Is the building flood-proofed?
Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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