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    On-Line Flood
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!


    Your Name:
    Property Address:
    City:
    State: (Must be Washington)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail (again for accuracy):
    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: 1 family Duplex
    3 Family 4 Family
     
    Type foundation: Slab Crawlspace over slab
    Pier & Post Other (list in remarks)
     
    Type Roof: Shingle Wood Shake
    Tar/Gravel Spanish Tile
     
    Number of stories: One 1.5
    Two Three
    If more than 1 story, are some contents on ground floor, contents ONLY above the first floor? On ground floor
    Above first floor only
     
    Currently Insured? Yes No
    Name of Carrier & how long insured?
    Prior Claims? Yes No
    Describe claims in detail:
     
    Plumbing type: Copper Galvanized
    Mixed (Copper/Galvanized)
     
    Circuit Breakers or fuses? Breakers Fuses

    # Bedrooms: # Bathrooms:
     
    # Fireplaces: # Chimneys:
     
    Special features
    (i.e., deck, air conditioning, alarm systems, pool, etc.)
     
    Coverages:
    Dwelling Cov. $ Contents $
    Deductible $
    ($250, $500, $1,000, etc.)
     
     
    Comments/Remarks:
     
    Send my quotation via: E-Mail Fax
    Regular Mail
    Call Me by Phone


    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

    Yes, I Agree. Please Send Me a Quote NOW!



    McGregor Insurance, Inc. - PO Box 429 - Ocean Shores, WA 98569 | PHONE: 360-289-2808 | FAX: 360-637-3523
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