Florida Flood Insurance Quote

Personal Information

I understand that Members Insurance Center is unable to assist with mobile home coverage at this time. ✶

First name ✶

Last name ✶

Street address ✶

City ✶

State ✶

ZIP ✶

Phone ✶

Email ✶

Preferred contact method(s) ✶

Call

Date of birth ✶

Occupation ✶

SSN (optional)

Bankruptcy or foreclosure in last 5 years? ✶

Yes

Co-Owner

Name

Relationship

Date of Birth

Home Information

Is this your primary residence? ✶

Yes

Is this a new purchase? ✶

Yes

Closing date ✶

Property Address

Where is the property located? ✶

At the address above

At a different address

Street address ✶

City ✶

State ✶

ZIP ✶

Year built ✶

Type ✶

Levels ✶

Construction ✶

Foundation ✶

Living space ✶

sq ft

Does any room inside the home have a step down to enter it? ✶

Yes

Finished basement? ✶

Yes

Finished bsmt size ✶

sq ft

Insurance Coverage Information

Do you have an Elevation Certificate for this property? ✶

Yes

Upload Elevation Certificate

Or email to membersinsurance [at] floridamic [dot] org

Claims History

# flood losses in last 5 years

Prior coverage cancelled or non-renewed in the last 3 years? ✶

Yes

Current Insurance

I currently have a flood insurance policy ✶

Yes

Insurance company

Current Premium

Renewal date

Building coverage

Current policy declarations page (PDF)

This is optional but can help us with the quoting process

Desired Insurance Coverage

Are you interested in learning more about any of these coverage options?

Flood

Jewelry/Personal Articles

Comments or questions

I understand that coverage cannot be bound or altered until the information has been confirmed by one of our representatives by phone or email. ✶

Subject

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Secure form

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FLOOD INSURANCE QUOTE

Personal Information

Home Information

Insurance Coverage Information