Cooper, Simms, Nelson, & Mosley World Wide Web Site Online Insurance Application
     IMPORTANT NOTICE: Please note that no coverage can be bound using e-Mail, the Internet, or by leaving a voice mail message. All requests must b conducted through our agency with signed applications. 

Toll Free: 1.877.644.2766                                                                                                     Providing Insurance Since 1934

 

 

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.

 

   

 

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