Flood Field Survey

Property Information

1. What year was this risk (home) built?

2. What year did you purchase this risk?

3. Do you own this risk (home) or are you buying it?

In whose name is the title or deed in?

4. What is the name of your mortgage company?

5. Are there any additional mortgages? If so, list them.

6. If mortgage paid off, give year paid off.

Flood History

7. Are you aware of any other flood losses?

Yes No

If so, were the repairs made to this risk?

Yes No

If yes, list year and amount of claim paid:

Water Details

8. What is the name of the nearest body of water?

9. Approximately how far is this water from risk (home)?

10. What date/time did the flood waters enter your risk?

Water Entered — Date & Time

Water Receded — Date & Time

Water height — Inside

Water height — Outside

Insurance Information

11. Do you have any other insurance besides this flood policy?

Yes No

If yes, company / type / policy number:

Building amount:

Contents amount:

Does this insurance cover flood damage?

Yes No

12. Is this your:

Principal Residence Seasonal Rental Property

Do you occasionally or permanently rent any portion of house?

Yes No

If yes, explain:

Additional Information

13. Have you done any kind of major improvements since owning?

Yes No

If yes, explain:

14. If rental, do you own all the contents you are claiming?

Yes No

15. Would you like an advance?

Yes No

16. Will you be using a general contractor to repair flood damages?

Yes No

Disclaimer: I agree that neither the Adjustment Company nor this Adjuster has the authority to approve or deny my claim. And I further agree if contents coverage is provided and claim is presented I will not discard any items being claimed, except perishable items. I also agree to the terms of Salvage and Subrogation recovery by my insurance carrier as set forth in the Policy. I also fully understand that if I do not provide a signed Proof of Loss within 60 days from the date of loss, my claim could be denied for failure to comply with Policy Provisions set forth in the Standard Flood Insurance Policy. "I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct."