Flood Insurance Quote
All Information submitted is held in the Strictest Confidence and is NOT being shared with anyone outside our company nor is it being used for marketing or advertising purposes, please also note that this is NOT an application for insurance, just a request for a quote. 
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About You

Name   *
Address  
City   State    Zip
County   *
Home Phone   *  Work Phone ext.#
Email Address   *
Marital Status  
Residence  
Occupation     

About Your Property

Price  Purchase Price / Replacement Cost of Dwelling
Amount of Mortgage   
Reason you require 
Flood Insurance 
 
Do you own the Property?   
How much coverage required for contents of home    

Select Property Type 
that may apply:  
  Owner Occupied    Rented to Others    Vacant
  1 Family    2 Family    3 Family   4 Family
  House    Condo or Co-Op    Apartment   Town House
  Row House (attached)   
Apartment Building
 
  Number of Bedrooms
  How many floors (including the basement) in your home?
 
Is there a basement?
 
Is the basement finished?

Other rooms (select all that apply) 
    Do NOT include rooms in the basement

  Den    Living Room   Rec. Room   Library   Pantry
  Eat-in Kitchen    Screened Porch    Dining Room   Deck

Additional Features (select all that apply)
  Fire Alarm   Burglar Alarm
  Marble Bath    Jetted Tub   Sauna    Jacuzzi
  In-Ground Pool    Above Ground Pool
  Sky Lights    Fire Place 
 

Contact your bank or local town hall, if you need help gathering this information:   Community Number
 
Flood Zone (A5, V, B, etc)

General Questions

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    121 East Sixth Avenue, Suite 103, Lancaster, Ohio 43130-0368
    Phone: 740-687-6258 or 800-734-3198 / Fax: 740-687-1836
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Email: KentMiller@Miller-Lewis.com