YOUR CONTACT INFORMATION

Full Name      

Address  

City 

State  ND MN

E-Mail   

Phone #     

I am the  Home Owner Home Buyer Loan Officer Realtor Other

YOUR PROPERTY INFORMATION

Address 

City 

State  ND MN

Zip Code 

Year Property Built

Building Type  Please Choose One Single Family Home 2 - 4 Family Mobile Home Townhouse - Rowhouse Condo Unit Non-Residential

Building Foundation  Please Choose One Slab on Grade Crawl Space Unfinished Basement Finished Basement Split Level Elevated Above Ground Other

Garage Type   Please Choose One Attached Detached Carport Built-In None

Number of Floors  Please Choose One 1 2 3 or more

BASIC UNDERWRITING INFORMATION

Occupancy Type  Primary Home Second Home Rental Unit Other

Do You have an Elevation Certificate?  Please Choose One Yes No No Idea What it is

Do You Currently Have Flood Insurance?  No Yes

If So, When Does it Expire?    mm/dd/yy

YOUR POLICY COVERAGE

Building Coverage Amount 
maximum coverage $250,000.  Please specify a dollar amount above.

Building Deductible Amount  $2000 $1000 $3000 $4000 $5000
maximum deductible is $5,000

Contents Coverage Amount 

Contents Deductible  $0 $1000 $2000 $3000 $4000 $5000

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