Wiglesworth - Rindom Insurance Agency

FLOOD RATING FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way does not obligate you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

First Name:

Last Name:

E-mail address:

Daytime Phone Number:

Evening Phone Number:

Address:

City:

State:

Zip code:

Closing Date if new Purchase:

STRUCTURAL INFORMATION

Do you have an Elevation Certificate?

Yes No

How many stories is your home?

COVERAGES AND DEDUCTIBLES

Dwelling (Coverage A - Replacement cost of your home):

Do you currently carry Flood Insurance?

Yes No

REMARKS

You could be eligible for a Preferred Risk Policy. Ask your Agent for details.

COVERAGE		PREMIUMS
Building	Contents	Without Basement
$50,000	$20,000	$196.00
$75,000	$30,000	$230.00
$100,000	$40,000	$257.00
$125,000	$50,000	$277.00
$150,000	$60,000	$296.00
$200,000	$80,000	$326.00
$250,000	$100,000	$348.00

QUOTATION FORMS
HOMEOWNERS | AUTOMOBILE | FLOOD