First Name:

Last Name:

Phone Number:

Fax:

Email:

Please either add interstateinsurance@yahoo.com to your address book or check your spam folder for reply email.

Address:

City:

Zip:

County:

Cost to Rebuild Dwelling:

Type:

What is the Year Built?

Total Sq/Ft under air:

How many Stories is the home?

Construction Type:

Roof Type:

Age of Roof:

Wind Mitigation Inspection?

Yes No

 

Current Insurance Company:

Annual Premium:

 Expiration Date:

Do you Escrow your insurance?

Do you currently have Flood insurance?

Note: This information is used to help us verify the reconstruction cost of your home and eligibility.

How many bedrooms?

How many bathrooms?

Attached Garage?

Yes No

If yes, number of cars:

Is there a swimming pool?

If yes, is it screened or fenced?

Do you have storm shutters?

Do you have an alarm activated?

Smoke detectors?

Is your home located in a Gated and or Guarded community?

Fireplace?

Purchase price?

How Old Is your Roof

Do you have a trampoline on premises?

Filed for Bankruptcy in the past 5 years?

Occupancy