Name used on policy:  _____________________________________________________

Name of County that address is located?  ______________________________

Is wind coverage to be included?  ____________________________________________

Is there a wind policy in place?  If so, please provide a copy of the declarations page.
_______________________________________________________________________

Is there a flood policy in place? ___________    Please provide Flood Zone ___________  If so, please provide a copy of the declarations page.

Please provide elevation of the top of the bottom floor & the base:
    Top of Bottom Floor Elevation _____________     Base Floor Elevation __________    

What is the distance to the ocean and/or Intercoastal waterway? (< 2,500’?)  __________

Does the property face the seaward side of the Intercoastal waterway?  _______________

Is the Property Shuttered?  _____________    Does the Property have Impact Glass? _____________

Roof shape? (flat, gable, gambrel, hip, mansard, shed, other) _______________________

Roof type? (tile, asphalt shingles, other) _______________________________________

Is the Home Located in a Gated Community? ___________________________________

Does the Neighborhood have a 24 hour Security Guard? _________________________

Please list all pets at this location?  ___________________________________________

Will the home be owner occupied at the time coverage is bound?  ___________________

Is the construction based on South Florida standards (built after 1996)?  ______________

If property is a condominium, what floor is condo located on?  _____________________

If property is a condominium, A&A coverage automatic for 10% of contents limit.  What is the additional amount of A&A coverage you are requesting?  ____________________

Please provide prior carrier / loss experience information. _________________________  ________________________________________________________________________

Has the insured had any losses at this location?  Is so, please provide details.__________ ________________________________________________________________________

Has the insured had any losses at a prior location?  If so, please provide details. ________
________________________________________________________________________