IMPORTANT NOTICE

1. This flood insurance quote request applies only to the states of Oregon and Washington. Do not fill out this form if you do not own property in Oregon or Washington.

2. No insurance will be started by submitting this form. Coverage may be placed in force, according to flood program rules, only after you decide to purchase it from us, and then after you complete and sign the flood insurance application and pay the initial premium.

3. Submitting the following quote request constitutes your agreement with the above statements. We will contact you within two business days after we receive your request. If you have questions concerning this notice or about the following form, please call us at 503-620-0230 or toll-free 1-888-620-0230.

Flood Insurance Quote Request
  1. Your First Name
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  2. Middle Name
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  3. Last Name
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  4. Name of Additional Owner
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  5. Email Address
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  6. Phone Number
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  7. Fax Number
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  8. Street Address
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  9. City
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  10. State
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  11. Zip Code
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  12. County
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  13. Mortgagee Loan #, Name and Address
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  14. Amount of Building Coverage
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  15. Amount of Contents Coverage
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  16. Year Built
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  17. Are You Required to Carry Flood Insurance?
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  18. Is the Building located on Federal Land?
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  19. Is the Building in the course of construction?
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  20. Is the Building your primary residence?
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  21. Is the Building State Government Ownerd?
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  22. Is this policy required for Disaster Assistance?
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  23. Is the garage attached to the building?
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  24. Is the Building over water?
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  25. Do you have a Floodproofing Certificate?
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  26. Do you have an Elevation Certificate?
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  27. Number of Floors
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  28. Basement
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  29. Describe machinery or appliances in basement
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  30. Foundation
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  31. Square Feet Crawl Space
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  32. Total Square Inches of Venting
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  33. Occupancy Type
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  34. If Condominium or Townhouse, Units Separated by



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  35. If Mobile Home, Its Length
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  36. If Mobile Home, Its Width
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  37. Additional information or comments
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  38. Re-type the Security Field numbers in the box
  39. Security Field
    Security Field
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  40. To keep a copy of this form, please Print before Submitting
  41.   

 

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Questions?

If you have questions concerning this information, please call us at 503-620-0230, or come in.

Llámenos ya al 503-620-0230.