Waddell Insurance Group

Wind Insurance Quote Request

Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way. If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me.

New:
Endorsement:
Title Transfer:
Previous or Current Policy #
Name:
Email:
Address:
City:
State:
Zip:
County:
Day Phone:
Evening Phone:
Occupancy:
Current Insurance Company:
Current Policy Renewal Date:

Mortgagee/Loss payee (Name and address)
Name:
Email:
Address:
City:
State:
Zip:
Loan #:
Payer:
If "Other", specify:

Dwelling Information
# of Stories:
Construction:
If "Other", specify:
Additional Info:
Property Secondary Residence	Yes No
Is Property Occupied by:	Owner Tenant
Tenant Content:	Yes No
Type of Roof:
If "Other", specify:
Roof Covering:
If "Other", specify:
Roof Sheathing Attachment:
Garage:
Openings:	(sliding glass doors: exits to porch, patio or exterior of dwelling)
Attached Porches/Carports:
Secondary Water Resistance:	Yes No
If yes, Which Type	Exterior Interior
Foundation Type:
Roof Tie Down Straps/Clips?	Yes No
Gable ends properly Braced?	Yes No
Reinforced Masonry Roof?	Yes No
Garage Door SSTD 12 or Dade County Approved?	Yes No
If no, is it braced with approved system?	Yes No
Amount of Insurance Requested on Dwelling:	$ (Replacement Cost, not Market Value)

If Condo/Apartment/Townhouse/Motel
Name of Complex:
Total # of units in building:
Specific Units #:
Above Ground Floor?	Yes No
Building No:
Phase #:

If Mobile Home
Compiles with ANSI/ANCE Code # 7-88:	Yes No
Model Year/Name:
Dimensions:
Mobile Home ID #:
Lot # & Mobile Home Park:

Property Location
Address:
City:
County:
State:
Zip:

Amount of Coverage

Amount Requested - Building:

Amount Requested - Contents:

$ (INC Additions & alterations) Limited to 50% of Building

Amount Requested - Other:

Underwriting Information

100% Replacement Cost - Building:

$ (N/A to Mobile Homes)

Actual Cash Value - Building:

Actual Cash Value - Contents:

This building was constructed:

year

Total Area of Building (sq feet):

Flood Insurance Carrier:

(Flood Policy mandatory in zones A & V)

Flood policy #:

Flood Zone:

Is there unrepaired Physical Damage to the Property?

Yes No

Is there losses in the last 2 years?

Yes No (If yes, indicate in the comments box.)

Homeowners/Fire Insurance Carrier:

Homeowners/Fire Policy #:

Insuring Limit on HO Policy (if known):

Deductible

Hurricane:	2% 3% 4% 5% $500 flat
Other - Wind:	2% 3% 4% 5% $500 flat

Windstorm Protective Device Credit?:

Yes No

If Yes:

Hurricane Ordinary

Additional Comments

I hereby certify that the information on this application is true and correct to the best of my knowledge.
Applicant Name:
Date:

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