14 Front Street, Hempstead, NY, 11550
Flood Insurance Quick Quote Short Form
Fields marked with an asterisk
( * )
Agency Email Address(*):
Agency Phone(*) #:
1. Named Insured(*):
2. Mailing Address(*):
3. Risk Location Address(*):
Location Address is Same as the Mailing Address
4. Insured’s Phone Number(*):
5. Effective Date Requested(*):
6. Date Purchased(*):
7. Is this a New Purchase?(*)
8. Building Type(*):
9. Occupancy Type(*):
3 or 4 Family
# of Units in Building
10. Type of Business(*):
Not a Business
11. Year Built(*):
12. Is the Building Under Construction?(*)
13. Is the Building Elevated?(*)
14. Do You Have an Elevation Certificate?(*)
15. Is the Building a Severe Repetitive Loss Property?(*)
16. Is the building located on federal land?(*)
17. Any additions/extensions other than an attached Garage?(*)
If Yes – Please Describe:
18. Is there an attached garage?(*)
i. What is the Square Footage?
ii. Is the garage area finished?
iii. Does garage have openings for water flow?
iv. Is there any equipment in the garage?
If Yes – Please List:
19. Is there a basement?(*)
i. Is the basement finished?
ii. Are Any of the Following Located in the Basement?
20. Building Coverage Needed(*):
21. Contents Coverage Needed(*):
22. Value of Entire Dwelling(*):
23. Are there any additional insureds needed?(*)
If YES Please List: