Miller-Lewis Insurance Agency, Inc.

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
Reply via:	Email Phone Mail
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    © 2010 Miller-Lewis Insurance Agency, Inc.
    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