Flood Insurance Form

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Property Location Address

Street *

City *

State *

ZIP / Postal Code *

Financial Information

Lien Holder

Street Address

City, State. ZIP Code

Loan #

Underwriting Questions

Building replacement cost of your home? *

Year home was built *

Construction *

Dwelling Type *

Does home have a basement? *

Dwelling *

Is this a Secondary Residence? *

Is the home occupied? *

Is this dwelling or any appurtenant structure near, or exposed to flooding from a river, stream, creek, canal, ditch, lake, resevoir, pond, arroyo or was, or seasonal runoff or accumulation or flow? *

If yes, how many horizontal feet is the home or structure away from the water? (in feet)

If yes, how many vertical feet does the home or structure lie above or below the water? (above/below in feet)

If yes, what is the name of the body or flow of water?

Is the home situated or built:

In the path of potential landslide, avalanche or mud flow? *

On the base of a steep slope? *

Upon a landfill? *

If any answer is "Yes", please explain fully and describe condition:

Is there any existing damage to structure such as cracking or settling of walls or foundations? *

If any answer is "Yes", please explain fully and describe condition:

Please advise if this home, appurtenant structure or nearby home has suffered damage from any of the following perils in the past (your answer should include any such losses that you are aware of, and must cover at least the past five years):

Flood *

Surface Water *

Landslide or Earth Movement *

If any answer is "Yes", please submit the following information: Fully describe the loss and provide specific details of measures taken to prevent similar losses, by the applicant or public authorities.

Is your mortgagee requiring the purchase of flood insurance on your home? *

If the answer is "Yes", please explain and include a full description of the flood plain surrounding your property.

Has any similar coverage as being applied for been declined, cancelled, or non-renewed for this home previously? *

If the answer is "Yes", please explain:

Is similar coverage as being applied for in effect now or has it been at any time in the past for this home? *

If the answer is "Yes", please provide carrier:

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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122 5th Ave W | Gooding, ID 83330 | Phone: 208.934.4781/208.934.4484