Social Security Number
2 to 4 Family
Condo Association and/or Residential Building?
Has property incurred 2 or more losses?
Total Building Coverage
Total Contents Coverage
Three or more floors
Construction Date (MM/DD/YYYY)
Number of units in building
Basement / Enclosure of Crawl Space:
Enclosure 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:
Solid Perimeter Walls
Lowest level used for:
Square footage of lowest level:
Lowest Floor Only – Above ground level
Lowest floor above ground level & higher floors
Above ground by one or more floors
Is the building flood-proofed?
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Name Of Your Company or type of business if seeking commercial insurance (required)
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