Earthquake/Flood Insurance Form Please enable JavaScript in your browser to complete this form. – Step 1 of 4Name *FirstLastBirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Marital Status *SingleMarriedDivorceWidowedLayoutIf married, partner's name *FirstLastPartner's BirthdateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NextEarthquake/FloodEarthquake cover from the ground up. So if you have a basement the earthquake will not cover. Also, you will need to pay your deductible first before getting any help with the earthquake. Flood would cover basement property. The water would need to be from outside of the home. For Example, heavy rain that causes water to come into your home.Deductible %, the dwelling value at time of loss *5%10%15%20%25%Building Occupancy Type *Single FamilyCondoTownhomeManufactured HomeBuilding Use *Primary HomeSecondary/seasonal homeProperty rented to othersIs the property under any construction? *YesNoWhat type of insurance? *EarthquakeFloodEarthquake and FloodNextConstruction Type *Wood Frame (most homes)Solid brickLog CabinNumber of stories above ground *OneTwoThreeFour or moreSquare footage of home above basement *Year home was built *Choose the following basement choices *BasementSlab on GradeRaised FoundationNextDwelling amount of your home, under Coverage A on your home policy page *Value of other structures in your yard. Ex a Shed or look at home policy under coverage B *Value of your personal property, under Coverage C on your home policy *Payment Option *Annual PayMonthly PayAny questions, please fill out below?Submit
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