LS INSURANCE SERVICE | Personal Flood Insurance Form

Personal Flood

Questionnaire

Insured Information

Need for Loan settlement:

Standard 30 day wait:

Insured's Name:

Above named is:

Additional Name:

Property Address:

City

State:

Zip:

Is Mailing Address the same as property Address:

Phone Number

Work Phone

Cell Phone

Fax

Email Address

Property Information

Occupancy Type:

Building Type:

Is building a Condo:

Is building Under Construction:

If under construction, Construction Date:

Is the building Elevated:

Basement/Enclosure Type:

Building Elevation Certificate:

Basement Information

Is the basement floor below grade on all four sides:

Is the interior floor of the basement/crawl space no more than 5 inches below the top ofthe next higher floor directly above the basement/crawl space:

Is the crawlspace certified by the community:

Does the basement contain machinery or equipment:

If "Yes" Please select Equipment.

Furnace:

Heat Pump:

Air Conditioner:

Oil Tank:

Water Heater:

Cistern:

Elevator Equipment:

Washer & Dryer:

Food Freezer:

Other Machinery or equipment servicing the building:

Is the basement used for any purpose other than storage:

Elevated Information

Foundation Construction:

Does the area below the elevated Floor contain machinery or equipment:

If "Yes" Please select Equipment.

Furnace:

Heat Pump:

Air Conditioner:

Oil Tank:

Water Heater:

Cistern:

Elevator Equipment:

Washer & Dryer:

Food Freezer:

Other Machinery or equipment servicing the building:

Estimated total square ft of enclosure:

Elevated floor is enclosed:

Materials used to enclose the area below the elevated floor:

Is the enclosed area constructed with openings to allow for the passage of flood waters(exclude doors):

Choose the # of permanent openings (flood vents within l'Ft of adjacent grade:

Enter the total area of all permanent opening (flood vents) in square inches:

Is the enclosed area used for any purpose other than solely for parking of vehicles, building access or storage:

Describe use of enclosed area:

Does the enclosed area have more than- 20 linear feet of finished wall, paneling, etc:

Garage Information

Attached Garage:

Elevation of garage floor:

Est. total sq footage of garage:

Openings to allow passage of flood waters (exclude doors):

Number of permanent openings within l'Ft of the adjacent grade:

Enter the total area of all permanent openings (flood vents in square inches):

Is the garage used solely for parking of vehicles, building access, and or storage:

Does the garage contain machinery or Equipment:

If "Yes" Please select Equipment.

Furnace:

Heat Pump:

Air Conditioner:

Oil Tank:

Water Heater:

Cistern:

Elevator Equipment:

Washer & Dryer:

Food Freezer:

Other Machinery or equipment servicing the building:

Lowest elevation of machinery and/or equipment servicing the building:

Approx. distance of site location to nearest shoreline:

Source of flooding:

Is building located above water:

If "yes" What part:

The lowest floor is (round to nearest ft) Above Below the lowest ground (grade) immediately next to the building.
The garage floor is (round to the nearest ft) Above Below the lowest ground (grade) immediately next to the building.
Machinery or equipment located at a level lower than the lowest floor is (round to the nearest foot) feet below the lowest floor.

Preferred Risk Eligibility

Do any ofthese conditions, arising from one or more occurrences exist within any 10 year period, regardless of property ownership:

2 loss payments, each more than $1,000:

3 or more loss payments, regardless of amount:

2 Federal Disaster relief payments, each more than $1,000:

3 Federal Disaster relief payments, regardless of amount:

1 flood insurance claim payment and 1 flood disaster relief payment (including loans and grants) each more than $l,OOO:

Information Source:

Building Coverage:

Deductible Amount?

Contents Coverage:

Deductible Amount?

Replacement Cost:

Contents location:

Is the personal property household Contents:

Contents description:

*If the building is a Post-Firm structure located in a Special Flood Hazard Area an Elevation Certificate is required. Standard rating cannot be completed without this necessary information.

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