Flood Insurance Online Application

First Name

Last Name

Daytime Phone

Evening Phone

Email Address

Street Address

County

State

Zip Code

Social Security Number

Building Occupancy

Please Select Single Occupancy 2 to 4 Family Other Residential Non-Residential

Condo Association and/or Residential Building?

Please Select Yes No

Has property incurred 2 or more losses?

Please Select Yes No

Replacement Cost

Total Building Coverage

Total Contents Coverage

Building Type

Please Select One Floor Split Level Two Floors Three or more floors Townhouse/Row House Manufactured Home

Construction Date (MM/DD/YYYY)

Number of units in building

Please Select 1 2 3 4 5 5+

Condo Association?

Please Select Yes No

Basement / Enclosure of Crawl Space:

Please Select None Basement Enclosure or Crawl Space

Does enclosure or crawl space area have compliant venting?

Please Select Yes No

Is the lowest level a finished area?

Please Select Yes No

Is machinery and/or equipment located on the lowest level?

Please Select Yes No

Is the building elevated?

Please Select Yes No

Lowest floor which includes living area, is off the ground by means of:

Please Select Piles Posts Piers Columns Solid Perimeter Walls Parallel Walls Concrete Walls Other

Lowest level used for:

Please Select Storage Parking Access Other

Square footage of lowest level:

Enclosure walls:

Please Select Solid Perimeter Breakaway Lattice Other

Contents location:

Please Select 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?

Please select Yes No

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@zolofrainsurance.com. Do not “Refresh” the page because all data entered onto the form will be lost.