Request a flood insurance quote for your home or building, including lender-required policies and escrow closings. Rated by our flood specialists; a licensed agent follows up.

1. How did you find us? (required; choices: Search engines / Social media / News story / Referral / I am a current client of Susman Insurance)
2. Name of Referral (required; only when applicable)
3. Are you working with one of our Agents? (required; choices: Yes / No)
4. Agent's Name (required; only when applicable)
5. First Name (required)
6. Middle Name (optional)
7. Last Name (required)
8. Home Phone: (required)
9. Email: (required)
10. Co Applicant: (optional)
11. Are you an escrow on this property? (required; choices: Yes / No)
12. Escrow information (required; only when applicable)
13. Effective Date Requested: (required)
14. Is there a current policy in place? (required; choices: Yes / No)
15. Is this an FHA Loan? (required; choices: Yes / No; only when applicable)
16. What is the renewal date? (required; date; only when applicable)
17. Property Type: (required; choices: Single family / Duplex / Triplex / 4-plex / 5 or more / Condo unit / Mobile Home / Non-residential / RCBAP)
18. Building Use: (required; choices: Main House / Detached Guest House / Detached Garage / Agricultural Building / Tool/storage shed / Pool house, recreational building / Other)
19. Occupancy: (required; choices: Primary / Secondary / Seasonal / Short Term Let / Rental / Vacant / COC / Commercial / Apartment Building)
20. Number of Stories in Building: (required; choices: 1 / 2 / 3 or more / Split Level / Townhouse/rowhouse / Mobile Home)
21. Building Purpose: (required; choices: 100% non-residential / Mixed-use / 100% residential)
22. Any Prior Losses? (required; choices: Yes / No)
23. Please explain: Year of loss/Total Payout (required; only when applicable)
24. Address (required)
25. Address line 2 (optional)
26. City/Town (required)
27. State/Region/Province (required)
28. Zip/Post Code (required)
29. Country (optional)
30. Have you had any claims in the last 5 years? (required; choices: Yes / No)
31. Is the Mailing Address same as the Property Address? (required; choices: Yes / No)
32. Address (required)
33. Address line 2 (optional)
34. City/Town (required)
35. State/Region/Province (required)
36. Zip/Post Code (required)
37. Country (optional)
38. Is premium to be paid by Bank on Renewal: (optional; choices: Yes / No)
39. Additional Interest Type: (optional; choices: Additional Insured / Loss Payee / Mortgagee)
40. Additional Interest Name: (optional)
41. Loan Number: (optional)
42. Address (optional)
43. Address line 2 (optional)
44. City/Town (optional)
45. State/Region/Province (optional)
46. Zip/Post Code (optional)
47. Country (optional)
48. Year Built: (required)
49. Any additions supported by piers or beams: (required; choices: Yes / No)
50. Square Footage: (required)
51. Foundation: (required; choices: Basement Fully Finished / Basement Partially Finished / Basement unfinished / Slab on Grade / Elevated Building - enclosure below / Elevated Building - no enclosure below / Walkout - Finished / Walkout - Unfinished / Crawl Space - below grade / Crawl Space - above grade)
52. Is there a Garage attached to or part of the Building? (required; choices: Yes / No)
53. Flood Dwelling Limit: (required)
54. Equipment/machinery in basement (if any): (optional)
55. Other Structures (other building, pool etc., if any): (optional)
56. Flood Personal Property Limit: (required)
57. Loss of use: (required)
58. Building Replacement Cost Limit: (required)
59. Deductible: (required)

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