A.J. Benet, Inc. -- Flood Insurance Quote Form

FLOOD
INSURANCE
QUOTE We would like to provide you with a free, no-obligation flood insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name:
Address:
City:	State: Zip:
Day Phone:	Night Phone:
Best Time To Call:	AM PM
Email Address:
Property Address (if different):
City:	State: Zip:

Current Flood Insurance Information

Company Name (not agency):

Policy Expiration Date: Policy Type: Primary Secondary

Home Information

How Long At Present Address: Year Home Was Built:
Lender Name:
Lender Address:

Sq. Footage (excluding garage
and basement): sq. ft. # of Claims In Last 3 Years:

Structure Information

Type Construction Roof Foundation Garage

Age of roof: yrs.

Coverage Desired

Deductible's: Dwelling:
Contents:

Dwelling Coverage: Select preset
limit below:
Or enter your own limit
(can't exceed $250,000):
$

Contents Coverage
(Personal Property): Select preset
limit below:
Or enter your own limit
(can't exceed $85,000):
$

Your Personal Property is Located: Basement Only
Basement and Above
Lowest Floor only above ground level (basement not incl)
Lowest floor above ground level and above

Miscellaneous Information

Do you qualify as a small business risk?: Yes No

Is building your principle residence?: Yes No

Is the building in the course of construction?: Yes No

Is insured property owned by state government?: Yes No

Is your building elevated?: Yes No

Is your building in a special flood hazard area? (if not certain leave blank): Yes No

FEMA (flood rate zone) (if not certain leave blank):

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

FLOOD INSURANCE QUOTE		We would like to provide you with a free, no-obligation flood insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Current Flood Insurance Information
Company Name (not agency):
Policy Expiration Date:	Policy Type: Primary Secondary

Home Information
How Long At Present Address:	Year Home Was Built:
Lender Name:
Lender Address:
Sq. Footage (excluding garage and basement):	sq. ft. # of Claims In Last 3 Years:

Structure Information
Type	Construction	Roof	Foundation	Garage

		Age of roof: yrs.

Coverage Desired
Deductible's:	Dwelling:	Contents:
Dwelling Coverage:	Select preset limit below:	Or enter your own limit (can't exceed $250,000): $
Contents Coverage (Personal Property):	Select preset limit below:	Or enter your own limit (can't exceed $85,000): $
Your Personal Property is Located:	Basement Only Basement and Above Lowest Floor only above ground level (basement not incl) Lowest floor above ground level and above

Miscellaneous Information
Do you qualify as a small business risk?:	Yes No
Is building your principle residence?:	Yes No
Is the building in the course of construction?:	Yes No
Is insured property owned by state government?:	Yes No
Is your building elevated?:	Yes No
Is your building in a special flood hazard area? (if not certain leave blank):	Yes No
FEMA (flood rate zone) (if not certain leave blank):