Flood Insurance
You will need to give us all the information below to receive an accurate quote.
When you have completed the form, click the SUBMIT button below. You may also print the form and mail or fax a copy to us.
Full Name:
Address:
City:
State:
ZIP:
Phone:
Fax (optional):
E-Mail:
Requested Effective Date:
Property Location
(Address):
Year Built:
Structure Type:
Brick
Frame
Dwelling Coverage Limits:
$
Contents Coverage Limit:
$
Primary Heat Source:
Electric
Natural Gas
Oil
Other
If oil, is tank in ground?
Yes
No
Square footage of living
space (if known):
Number of floors:
Is there a basement?
Yes
No
Is the building elevated?
Yes
No
Schedule of Personal Property
Jewelry Limit:
$
Fur Limit:
$
Fine Art:$
$
Current Insurer
Insurer:
Policy Number:
Expiration Date:
J. Stine Agency, Inc.
65 First Avenue ♦ PO Box 265
Atlantic Highlands, New Jersey 07716
Phone: 732.291.8773 ♦ Fax: 732.291.1846
©J. Stine Agency, Inc.
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