Coverage Request Form

 

Agency: Certificate #:   (#-###-##)
Mailing Address: City:  State:  ZIP: 
Building Name: Bldg. Number:  County: 
Location Address: City:  State:  ZIP: 
Flood Zone: # Stories:  Basement: 
Inside City Limits: Most Recent Construction Year: Sq. Footage: 
Occupancy: If Other, provide description: Sprinklered:   %

GPS with Tutorial: (Use http://map.floridadisaster.org . Use USNG and DD:dd coordinates only.)
USNG: 
Example: 17R ML 12345 54321
LAT N: 
Example: 28.12345
LONG W: 
Example: -82.12345

EXTERIOR WALL:
Type:  Subtype: 


ROOF SUPPORTS:
Type:  Subtype: 


AMOUNT OF ACV INSURANCE:
Building: $ Contents: $ Rental: $ Replacement (Bldg Only): $

Is building owned by any Agency, Board or Bureau of the State of Florida?    
Nearest Hydrant:     Feet
Distance to Ocean/Gulf:     (Miles)
Fire Department Name:    
Fire Pump:     If yes, type:    
Security: (Indicate all that are applicable.)
Watchman: Protected Signaling Systems:
Alarm Services: Alarm Systems:
Water Supply:
GENERATOR:  Manufacturer:  KW:     Gal:     Fuel:    
WAREHOUSING: (Describe any large scale storage of goods or products.)
HAZARDS: (Haz-mat handling, tanks of volatile gas, nuclear material, etc.)

Requested By Name: Title:
Phone Number: Date:

* By placing your initials here, you are thereby signing this document with your signature.       Electronic Signature:


electronic version (DFS-DO-850)
(Revised 11/(Revised 11/2005)
Rule 69H-1.003