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Private Flood Application

Insured: *

Name *

First

Last

Co Borrower (If Applicable)

First

Last

Phone *

Email *

Property Address *

Mailing Address (If Different Than Property Address)

Have there been any loses in the last 10 years? *

Yes
No

*If Yes please fill out the information below.

Number of Losses (within the last 10 years)

Loss Date

Building Loss Amount

Contents Loss Amount

*Insurance meets first mortgagee requirements for flood insurance.

--------- PROPERTY INFO ---------

Year Built *

Number of Floors (including basement) *

Square Footage of Property: *

Foundation Type: *

Above Grade Crawlspace
Elevated without Enclosure
Walkout Basement/Enclosure
Basement
Slab on Grade
Below Grade Crawlspace
Split Level Basement
Elevated with Enclosure
Split Level Slab on Grade

Construction Type: *

Wood Frame
Stucco
Unreinforced Masonry
Reinforced Masonry
Masonry
Masonry Veneer
Mobile Home With Tie Downs
Mobile Home Without Tie Downs

Occupancy Type: *

Single Family
Mobile Home
Condominium
Two to Four Family
Townhouse / Rowhouse

Reason for Request Coverage *

Loan Closing
Expiration of Prior Coverage
Other

Property Occupancy *

Primary Residence
Secondary Residence
Property Rented

Date Roof Last Updated *

Is the building over water: *

Yes
No

Is the building under construction: *

Yes
No

--------- COVERAGE INFO ---------

Requested Coverage Amount: *

Requested Contents Amount: *

Requested Effective Date *

--------- MORTGAGE INFO ---------

Mortgage Name *

Address (city, state, zip) *

Loan # *

Phone *

Email (If Available)

Name