Name
Phone







6650 Reseda Blvd
Suite #108
Reseda, CA 91335

contact@gisinsure.com
Flood Coverage Insurance
First Name:
Last Name:
Phone Number:
Fax Number:
E-Mail Address:
Who Referred You To Our Site?

Property Information

You must contact your community for the flood zone to complete the flood coverage worksheet.
 

Property Address:

 

Property City:
Property State:
Property Zip Code:
Dwelling Type:  
Flood Map Zone Number:
Community Flood Number:
Numbers Of Bedrooms:
Number Of Bathrooms:
Number of Fireplaces:
Garage Description:  
Year Built:
Date You Purchased Your Home:
How Many Stories:
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
Does The Dwelling Have A Basement? yes  no  
Construction Type:  
Roof Type:  
Roof Updated: yes no  
If Yes, Year Roof was Updated:
Property Topography:  
Foundation Type:  
Protection Distance:
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? yes no  
Smoke Alarm: yes no
Fire Extinguisher: yes no  
Electrical Updated:
Circuit Breakers: yes no
Copper Wiring: yes no
Heating - Air Conditioning, How Old?:
Heating - Air Conditioning, Thermostatically Controlled?: yes no 
Energy Source: 
Heating - Air Conditioning, Central? yes no 
Plumbing Updated: yes no
If Yes, Year Plumbing was Updated:
Copper Plumbing: yes no  
Interior Automatic Fire Sprinklers: 
Fire Alarm:
Fire District:
Current Insurance Company:
Expiration Date of Current Insurance Policy:
Losses-Claims in the last 5 years:   
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:
Questions or Comments
to help the Agent: