Thurston Insurance

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On-Line Flood Insurance Quote Form
	Your Personal Data:
*Your Name
*Street Address
*City
*State
*Zip Code
*E-Mail
E-Mail (repeat)
*Phone
fax(optional)


	Dwelling Information
*Year home Built
*Home square footage
Flood Zone NUMBER (look on current policy, if any)
Flood Community NUMBER (look on current policy, if any)
Number of units
Type of foundation
Type of roof
Number of stories
If more than 1 story, are some contents on ground floor, contents ONLY above the first floor?
Currently insured?
If yes, name of Carrier & how long insured?
Prior claims?
If yes, describe in detail
Plumbing type
Circuit breakers or fuses?
*# of bedrooms
*# of bathrooms
*# of Fireplaces
*# of chimneys
Special features (i.e., deck, air conditioning, alarm systems, pool, etc.)

	Coverages
*Dwelling coverage ($)
*Contents coverage ($)
*Deductible ($) (250, 500, 1,000, etc.)

Comments or remarks
*Send my quotation via	E-Mail Fax regular Mail call me by phone

	* denotes required field

Thank you!