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:
Physical Location to be insured:
(ex: owner primary , owner secondary, tenant occupied, Vacation, under 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 and square ft can be found on hcad.org Real Property Search)
Number of Stories:
Building over water?
(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)
Phone # if known:
Fax # if known:
For your quote, copy and paste this into an email to: email@example.com
or Fax to our office: (281) 290-6868
Mon-Fri 8am-5pm, (closed 12pm-1pm for lunch.