** Flood Insurance Order Form **


If new account, please complete the setup form.	Get more information about our services.

* = REQUIRED INFORMATION

FLOOD INSURANCE UNDERWRITING FORM

*Requestor (Your Name):
Agent Code:
* E-Mail Address:
* Phone:
Fax:
* Customer Name:
Loan Number:
* Property Address:
* City:
* State:	* Zip:
Flood Zone:
FEMA Community Number:
Panel:
Suffix:

* BUILDING TYPE:

Single Family Dwelling
2-4 Family Dwelling	Unit Count:
Other Residential	Unit Count:
Non-Residential	Unit Count:
Small business

* Slab on ground level? Yes No

* Basement: Yes No

COVERAGE
Amounts Requested:

* Date of Construction:

* Building Replacement Cost:
* Contents Coverage Amount:

* Number of Floors:

DEDUCTIBLE
Amounts Requested:

CONDO: Yes No
Entire Building
Unit Owner

Building
Contents

Mobile Home:
Yes No

Anchored:
Yes No

In Mobile Home Park?
Yes No

Mobile Home park date:

Make:

Model:

Serial Number:

Dimensions:

BUILDING INFORMATION CHECK SHEET

1. Site Location

  a) Approximate distance of site location nearest shoreline:

Less than 200 feet 500 to 1000 feet

200 to 500 feet Over 1000 feet

  b) Source of Flooding:

Ocean River or Stream

Lake Other

2. Basement

  a) Is the basement / crawlspace floor below grade on all four sides?
Yes No

  b) Does the basement contain machinery or equipment?
Yes No

  If yes, check the appropriate items:

Furnace Other equipment or machinery servicing the building

Hot water heater Air conditioner

Elevator equipment Oil tank

Cistern

  c) Is the basement used for any purpose other than storage?
Yes No

* 3. Garage

Does this building have a garage?
Yes No

a) Is the garage attached to the building?
Yes No

b) Square footage of garage:

c) Are there any openings or breakout panels (excluding doors) that are designed to allow the passage of flood waters into the garage?
Yes No

1) Size of each vent:

2) Vents within 1 foot of grade or ground? (not to exceed 1 Ft.):
Yes No

    If yes, describe:

d) Does the enclosed area have more than 20 linear feet of finished wall paneling, etc.?
Yes No

e) Is the garage used solely for parking of vehicles, building access, or storage?
Yes No

  If no, check the appropriate items:

Furnace Other equipment or machinery servicing the building

Hot water heater Air conditioner

Elevator equipment Oil tank

Cistern

Is this building elevated above ground level? (Examples: Raised foundation, crawlspace, or piers above ground level)
Yes No

ELEVATED BUILDINGS (INCLUDING MOBILE HOMES)

1.  Elevation Foundation of the building:
    Piers, posts, or Piles
    Reinforced masonry piers or concrete peirs or columns
    Reinforced concrete shear walls
    Solid perimeter walls

2.  Does the area below the elevated floor contain machinery or equipment?
     Yes      No

  If yes, check on one of the following:

Furnace	Other equipment or machinery servicing the building
Hot water heater	Air conditioner
Elevator equipment	Oil tank
Cistern
	Type:

3.  Area below the elevated floor:

    a) Is the area below the elevated floor enclosed?
     Yes      No

    If yes, check on one of the following:
     Partially      Fully

    b) Is the enclosed area greater than 300 square feet?
     Yes      No

  If yes, estimate size of area:

    a) Is the area below the elevated floor enclosed using materials other than insect screening or light wood latice?
     Yes      No

    If yes, check on one of the following:
     Partially
     Solid wood frame walls
     Masonry walls
     Other

    d) Is the enclosed area constructed with openings (excluding doors) to allow passage of flood waters through the enclosed area?
     Yes      No

  1) Number of vents:
  2) Size of each vent:
  3) Vents within 1 foot of grade or ground? (not to exceed 1 Ft.):
     Yes      No

    e) Is the enclosed area used for any purpose other than solely for parking of vehicle, building access, or storage?
     Yes      No

  If yes, describe:

    f) Does the enclosed area have more than 20 linear feet of finished wall paneling, etc?
     Yes      No

* Is this flood policy required by a lender?
Yes No

MORTGAGEE INFORMATION

Lender Name:
Mailing Address:
City:
State:	Zip:
1^ST Mortgagee Clause
2^ND Mortgagee Clause
Send Renewal Bill to: Insured 1^ST Mortgagee 2^ND Mortgagee

For loan closings, polices become effective on the day of the closing when premium is collected at the closing and forwarded to us. Lender purchased forced order NFIP policies become effective on the day America's Flood Insurance Services receives the premium payment. All other NFIP polices become effective 30 days after we receive payment. For Excess Flood or Private Lender Purchased Flood policies, please call 800-333-0883.

E-mail: customerservice@americasflood.com