PRP Eligibility Clarification
A claim payment (building and/or contents) and a Federal flood disaster relief payment (including loans and grants) for the same loss will be considered a single payment. Federal disaster relief payments are considered only if the building suffered flood damage.
Please provide the following information:
Personal Information		Please provide the following
First Name
Last Name
Middle Initial
Age		18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 52 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80
Date of Birth		January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985
Street Address
Address (cont.)
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Non-Bus NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa
Zip/Postal Code
County
Home Phone		(123-456-7890)
Work Phone
FAX
E-mail
URL
Length at Address				Months Years Days
Occupied By Applicant		Yes No
Contact Time		Anytime Before 8 am After 5 pm
Respond Time		Within 24 Hours Next Week Next Month
Is the Building located in a Special Flood Hazard Area on a Flood Hazard Boundary Map, or on a Flood Insurance Rate Map Zone A, AE, A1-A30, AO, AH, A99, V, VE, V1-V30, AR, AR dual zones AR/AE, AR/AH, AR/AO, AR/A1-A20, AR/A?		Yes No
Do any of the following conditions, arising from one or more occurrence, exist?		Yes No
		1 flood insurance claim payment and 1 Federal Disaster Relief payment (including loans and grants), each more than $1,000, have been paid. 2 loss payments, each more than $1,000. 3 or more loss payments, regardless of amount, have been paid. 2 Federal Disaster Relief payments, each more than $1,000, have been paid. 3 Federal Disaster Relief payments, regardless of amount, have been paid.
Residence To Be Quoted		[top] [bottom]
Same as Above		No - See Below Yes
Street Address
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Non-Bus NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa
Zip/Postal Code
County
Policy Information		[top] [bottom]
Renewal Billing		Insured 1st Mortgagee 2nd Mortgagee Loss Payee
Policy Type		New Renew
Current Policy Number			or		_ N/A
Waiting Period		Select Waiting Period Standard 30-Day Loan Closing - No Wait
Lender Waiting Requirement		SFHA - No Wait Non SFHA - 30 Day
Policy Effective Date:				(MM/DD/YYYY)
		Important information! A replacement policy can be issued with out a lapse in coverage provided the full premium and a copy of the prior declarations page showing expiration date of the prior policy is received no later than 30 days after the expiration date If the policy is submitted electronically using the ACH or Credit Card payment process, please indicate the new policy number on the prior declarations page and fax it to:
First Mortgage Information		[top] [bottom]
Loan Number
Name
Name 2
Address
Address 2
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Non-Bus NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa
Zip
Second  Mortgage Information		[top] [bottom]
Loan Number
Name
Name 2
Address
Address 2
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Non-Bus NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa
Zip
Loss Payee Information		[top] [bottom]
Loan Number
Name
Name 2
Address
Address 2
City
State		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico NY Non-Bus NY Business North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Guam Puerto Rico Virgin Islands American Samoa
Zip
Rating Information		[top] [bottom]
Flood Zone		Unknown B C X
Date of Construction or Substantial Improvement:				(MM/DD/YYYY)
Occupancy		Single Family 2-4 Family Other Residential Non-Residential
Number of Floors in entire building		Single Floor 2 Floors 3 or More Floors Split Level Mobile Home - Fill Out Section D
Foundation		Building Has Basement/Enclosure Building Does Not Have Basement/Enclosure
Is the building a rowhouse/townhouse condominium unit? Condo units in rowhouse/townhouse structures are eligible for PRP policies.		No Yes
Is property located in an unincorporated area of county?		No Yes
Is the building in the course of construction?		No Yes
Is this policy required for Disaster Assistance?		No Yes
Is the building insured's principal residence?		Yes No
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