Premier Services - The Insurance Experts

Flood Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Name:

Address:

City, State, Zip Code:

Phone:

Fax:

E-Mail:

Your age:

Age of building:

County:

Construction of building:

Occupancy - is dwelling:

Loss/claims history: Please state date, amount paid and details:

Approximate market value of dwelling:

Estimated replacement cost of dwelling:

If settlement, total amount of mortgage:

Number of units:

How many units presently occupied?

What is the community number?

What is the flood zone number?

If building is built after 1980 do you have an elevation number? Yes No

If so, what is the lowest floor elevation in feet?

What is the base floor elevation in feet?

Is building elevated? Yes No

Is there a basement? Yes No

If no, is there a fill or crawl space? Yes No

Do you engage in any work from the home to earn extra income? If so, please explain:

Current insurance carrier:

Expiration date:

Premium paid:

Coverages

Building amount:

Contents amount:

Dwelling deductible:

Contents deductible:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What specific coverages were quoted? (e.g., dwelling amount, contents amount, deductible options, etc.)

What was the price quoted?

How did you hear about us?

Additional Comments: