Personal Flood Insurance Quotation

Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process. We also collect the same information as part of service and update activities. The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

GENERAL INFORMATION

Name of Insured / Corporation / Property

DBA (if applicable)

Mailing Address

City

State Zip

Company Web site Address
Any Claims / Losses?	YES No
Reason for Request
Is Location Insured's Principal Address?

PHYSICAL LOCATIONS (if more than 5 include in Notes Section on Bottom of Page)
Address	Mkt Value	Bldg Amt.	Contents Amt.
LOC 1.
LOC 2.
LOC 3.
LOC 4.
LOC 5.

LOCATION INFO

Construction Date

Property Type

    Occupancy Type

    Other Occupancy Type

Number of Units

Construction Type

Basement Type

    If Basement
    - Does it hold Equipment (describe)

Number of Stories

Is There More Than 1 Building? YES No

# of Buildings

If More Than 1 Building - Distance Between?

Is This an Elevated Building? YES No

Is Garage Attached to Building? YES No

    If Attached
     - List Equipment or Machinery Stored

COVERAGE INFO

Contents Coverage

Contents Coverage Deductible

Building Coverage

Building Coverage Deductible

Estimated Replacement Cost

CONTACT INFORMATION
First Name Last Name Email Phone Fax Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!

All quotes are based on the information that the applicant provides, and are subject to change based on final underwriting by the individual carriers.

Our Mission Statement

Dating back from 1872 our mission is clear:

To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing

Policy Coverage
and Disclaimer

Contact

	Haines & Haines/ T.C. Irons
16 West Front Street Florence, NJ 08518 Phone: 609.499.0237 Fax: 609.499.4077	230 High Street PO Box 158- Burlington, NJ 08016 Phone: 609.387.0606 Fax: 609.387.5337	1-3 Bank Street Suite E Medford, NJ 08055 Phone: 609-953-2282 Fax: 609.953.7719
	Wesley Insurance Service Agency 1194 Parkway Avenue Trenton, NJ 08628 Phone: 609.883.4190 Fax: 609.538.0274