Serving Clients Since 1927

Omaha (402) 398-9009 | Kearney (308) 234-5258

Flood Insurance Form

Complete this form for a Flood Quote

Name

Mailing Address

City

State

Zip Code

Telephone

Email Address

Property Location

Property Address

City

State

Zip Code

Mortgage

Lender Name

Loan Number

Mailing Address

City

State

Zip Code

Rating Information

Building Occupancy
Single Family2-4 FamilyOther ResidentialNon-Residential

Basement\Encloser (all four sides underground)
NoneFinishedUnfinishedl

Building Type (include basement if any)
1 Floor2 Floors3 FloorsSplit-levelMobile home

Is the property owned by the government?
NoStateFederal

Is the building in the course of construction?
NoYes

Years of Construction

Contents Located
Basement onlyBasement and aboveLowest floor above groundLowest floor above ground and higherAbove ground level, more than one floor

Are contents household?
YesNo

if no, describe:

Replacement Cost of Building

Amount of Insurance

Residential Building (up to $250,000)

Residential Contents (up to $100,000)

non-Residential Building (up to $500,000)

non-Residential Contents (up to $500,000)

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