Flood Quote (Any information is kept confidential and is only for underwriting purposes. This information will only used by Florida Direct Insurance Agency, Inc .or its' subsidiaries only)
Primary Name Email Date of Birth Social Security # Occupation
Secondary Name (if applicable) Email Date of Birth Social Security # Occupation
Home Phone # - - Work Phone # - - Cell # - -
Physical Address City County State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Mailing Address City State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Best Time to Call 8:00am - 9:00am 9:00am - 11:00am 11:00am - 1:00pm 1:00pm - 3:00pm 3:00pm - 5:00pm 5:00pm - 8:00pm Best Place to Call Home Work Cell
Effective Date of Coverage Needed Prior Insurance Carrier Prior Policy #
Date of Expiration of Prior Coverage Years With Prior Carrier 0 1 2 3 4 5 or more Have You Ever Declared Bankruptcy Yes No
Do You Have Good Credit Yes No Have you had any homeowner or property related claims in the past five years? Yes No
If you have had any losses:
Date Details of Loss (Be brief) Amount of Claim
Year Built Value of Home Value of Contents
Deductible Requested for All other Perils $500 $1000 $2500 $5000 $10000
Type of Construction Frame Concrete Block Solid Concrete Concrete/Styrofoam Wood Other
Type of Garage None 1 Carport 2 Carport 3 Carport 1 Car Garage-Attached 2 Car Garage-Attached 3 Car Garage-Attached 1 Car Garage-Detached 2 Car Garage-Detached 3 Car Garage-Detached
Is the Home on piers, stilts, pilings, or other similar structures No Yes
Is your home located on Open Water, Bay, Gulf, or Ocean Yes No
Do you have an "Elevation Certificate" for your home (should had of been obtained at time of closing) Yes No
Additional Information :
Please send Fax Elevation Certificate to (800)801-8859 after completing form if available