Dale A. Cannon Agency


RESIDENTIAL FLOOD INSURANCE QUESTIONNAIRE  – No Waiting Period in most cases


Building Purpose:  Residential  
Effective Date Desired:
(Indicate a date or “asap”. Moratorium may prevent coverage from beginning when desired)


Company or Individual owned?


Personalize description of what you are quoting? 
 (ex, home, office, duplex, apartment, lakehouse, renthouse on main st)


Name of Individual  owner or Company/Organization:
If married, list Spouse Name: 

Mailing Address:

Phone:

Email:


Physical Location to be insured:
County:


Occupancy:
(ex: owner primary , owner secondary, tenant occupied, Vacation, under construction)


Construction:
(ex: brick veneer, ext insulation finishing system, frame, log, masonry, stucco, asbestos)


Dwelling Cost to rebuild new: $


Personal Property (contents) Value: $

Is this value the replacement cost to buy all your contents  brand new?


Year Built:
(Year and square ft can be found on hcad.org  Real Property Search)

Square Footage:


Number of Stories:

Building Elevated?
Building over water?


Foundation:
(Ex: Slab, foundation wall, slab on fill)


Height (in feet) above ground of the lowest occupied floor:
(ex: 0 ft,  1 ft, 2 ft, etc.  Typical home is zero)


Any past flood claims ?

(Give year of loss, value of loss, was home elevated after the loss?)


Which deductible(s) do you want quoted: 
 ($1,000  $2,000 $5,000, $10,000)


Mortgage Co  (optional for quote, include if making purchase of policy)
Name:
Address:
Loan #:
Phone # if known:
Fax # if known:

For your quote, copy and paste this into an email to:  cannond@nationwide.com

or Fax to our office: (281) 290-6868