Holder Insurance Agency

Flood Insurance Request Form

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

Information

Please be sure to complete all of the requested information so that your agent may contact you after receiving this notification.

Named Insured:

Address:

City:

State:

Zip:

Day Phone:

Beeper:

Eve. Phone:

Cell Phone:

E-mail Address:

Best Time To Contact:

AM PM

Method of contact:

Day Phone Eve. Phone Beeper
Cell Email

Current Policy Information

Agent:

Insurance Company:

Policy Number:

Policy Expiration Date:

Mortgagee/Loss payee (Name and address)
Name:
Email:
Address:
City:
State:
Zip:
Loan #:
Payor:
If "Other", specify:

Dwelling Information
# of Stories:
Construction:
If "Other", specify:
Additional Info:
Property Secondary Residence	Yes No
Is Property Occupied by:	Owner Tenant
Tenant Content:	Yes No
Type of Roof:
If "Other", specify:
Roof Covering:
If "Other", specify:
Roof Sheathing Attachment:
Garage:
Openings:	(sliding glass doors: exits to porch, patio or exterior of dwelling)
Attached Porches/Carports:
Secondary Water Resistance:	Yes No
If yes, Which Type	Exterior Interior
Foundation Type:
Roof Tie Down Straps/Clips?	Yes No
Gable ends properly Braced?	Yes No
Reinforced Masonry Roof?	Yes No
Garage Door SSTD 12 or Dade County Approved?	Yes No
If no, is it braced with approved system?	Yes No
Amount of Insurance Requested on Dwelling:	$(Replacement Cost, not Market Value)

Amount of Coverage
Amount Requested - Building:	$
Amount Requested - Contents:	$ (INC Additions & alterations) Limited to 50% of Building
Amount Requested - Other:	$
Underwriting Information
100% Replacement Cost - Building:	$ (N/A to Mobile Homes)
Actual Cash Value - Building:	$
Actual Cash Value - Contents:	$
This building was constructed:	year
Total Area of Building (sq feet):
Flood Insurance Carrier:	(Flood Policy mandatory in zones A & V)
Flood policy #:
Flood Zone:
Is there unrepaired Physical Damage to the Property?	Yes No
Is there losses in the last 2 years?	Yes No (If yes, indicate in the comments box.)
Homeowners/Fire Insurance Carrier:
Homeowners/Fire Policy #:
Insuring Limit on HO Policy (if known):

Additional Comments

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