FLOOD COVERAGE WORKSHEET

First Name: Last Name: Phone Number: Fax Number: E-Mail Address:    PROPERTY INFORMATION   You must contact your community for the flood zone to complete the flood coverage worksheet.   Property Address:   Property City: Property State: California Property Zip Code: Dwelling Type: House - Owner Occupied Condo - Owner Occupied Townhome - Owner Occupied Renter - (Any Dwelling Type) Rental Income 1-4 Units - Tenant Occupied Rental Income 5+ Units - Tenant Occupied Commercial Income - Office Type Commercial Income - Retail Type Commercial Income - Other   Flood Map Zone Number: Community Flood Number: Numbers Of Bedrooms: Number Of Bathrooms: Number of Fireplaces: Garage Description: No Carport - Garage 1 Car Carport - Attached 2 Car Carport - Attached 1 Car Carport - Detached 2 Car Carport - Detached 1 Car Garage - Attached 2 Car Garage - Attached 3 Car Garage - Attached 1 Car Garage - Detached 2 Car Garage - Detached 3 Car Garage - Detached   Year Built: Date You Purchased Your Home: How Many Stories: 1 2  If Two Stories, Ground Floor Square Footage:   Total Square Footage of Your Dwelling:   Does The Dwelling Have A Basement? yes no  Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Year Roof was Updated: Property Topography: >Flat Land Next To A Cliff Terraced (Sloped) On A Hill Under 15% On A Hill 16-30% On A Steep Hill Over 30% Gentle Hillside  Foundation Type: Concrete Slab Poured Perimeter Built On Pillars-Piers Rubble Stone Brick Masonry   Protection Distance: Under 1000 ft to hydrant & less than 5 mi to fire station Over 1000 ft to hydrant & less than 5 mi to fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  Is Dwelling in the Brush? yes no  Is there a Brush Hazard within (1) mile of Your Dwelling: yes no  If yes, has the Brush been cleared by 250 feet from all sides of Your Dwelling? yesno  Smoke Alarm: yesno Fire Extinguisher: yesno  Electrical Updated: Yes, Recently Updated No  Circuit Breakers: yes no Copper Wiring: yes no Heating - Air Conditioning, How Old?: Heating - Air Conditioning, Thermostatically Controlled?: yesno  Energy Source:  Gas Electrical  Heating - Air Conditioning, Central? yes no  Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Copper Plumbing: yes no  Interior Automatic Fire Sprinklers:  None Partial Full  Fire Alarm: None Local  Fire District: Current Insurance Company: Expiration Date of Current Insurance Policy: Losses-Claims in the last 5 years:  None One Two Three Four Five   If Yes, Date, Amount Paid & Description of Each Loss-Claim    COVERAGE INFORMATION   Dwelling Amount (Coverage A):   Other Structures (Coverage B): Personal Property (Coverage C): Loss of Use (Coverage D): Policy Deductible: 100 250 500 750 1000 2500 5000  Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.