Please provide the following contact information:

**Name
**Street address
Address (cont.)
**City
**State/Province
**Zip/Postal code
Work Phone
Home Phone
**E-mail

**Enter your county in the space provided below.

Enter your municipality in the space provided below. (township/borough/city)

Enter your flood zone in the space provided below. If you do not know your flood zone we will provide you with a quote for a Preferred Risk Policy. If you would like help in determining your flood zone, please call 1-800-829-1779.

**Enter the date of construction: (If there has been a significant improvement increasing the value by at least 50%, use the date of that most recent improvement) If you do not know the exact date, please estimate.

-- mm/dd/yy

**Is there a basement? (Any area below ground level on all 4 sides)

Yes No

**Is the basement finished? (Select either "Yes" or "No" if there IS a basement. If there IS NOT a basement select "N/A")

Yes No N/A

**What is the replacement cost of the building? (not including the land) If you are not sure, please estimate.

**Choose one of the following options to describe the building occupancy:

Single Family 2-4 Family Other Residential Non-Residential

**Choose one of the following options to describe the building style: (include basement in number of floors)

1 Floor 2 Floors 3 or more Split Level Condo (Townhouse/Rowhouse)

**How much coverage for damage to the building do you require? This amount cannot exceed the replacement cost of the building.

**How much coverage for damage to contents do you require? If you do not require any contents coverage, please enter "0".