Florida Flood Insurance - low cost coverage and high priced service!

Vista Healthplan, Inc.

Thanks for using our services!

© 2004 J.A. MESSINA INSURANCE
PO Box 244571
Boynton Beach, FL 33424-4571
Phone: 561-736-2162
Fax: 561-736-0228
License#A177282
E-Mail us at:
jamessinains@comcast.net

For Your Convenience,
We gladly accept:

"All Our Policies Come With
an Agent!"

Need Coverage TODAY? After Submitting
Your Quote Form (see below), Call Toll-Free:
1-800-735-2162
(Monday-Friday 9:00am-5:00pm Florida local time)

On-Line Flood
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!

Your Name:

Property Address:

City:

State: MUST be Florida!

Zip/Postal:

E-Mail (REQUIRED):

E-Mail (again for accuracy):

Phone:

Fax (optional):

Dwelling Information

Year Home Built:

Home Square footage:

Flood ZONE NUMBER:
(look on current policy, if any)

Flood COMMUNITY NUMBER:
(look on current policy, if any.)

Number of units: 1 family Duplex
3 Family 4 Family

Type foundation: Slab Crawlspace over slab
Pier & Post Other (list in remarks)

Type Roof: Shingle Wood Shake
Tar/Gravel Spanish Tile

Number of stories: One 1.5
Two Three

If more than 1 story, are some contents on ground floor, contents ONLY above the first floor? On ground floor
Above first floor only

Currently Insured? Yes No

Name of Carrier & how long insured?

Prior Claims? Yes No

Describe claims in detail:

Plumbing type: Copper Galvanized
Mixed (Copper/Galvanized)

Circuit Breakers or fuses? Breakers Fuses

# Bedrooms: # Bathrooms:

# Fireplaces: # Chimneys:

Special features
(i.e., deck, air conditioning, alarm systems, pool, etc.)

Coverages:

Dwelling Cov. $ Contents $

Deductible $
($250, $500, $1,000, etc.)

Comments/Remarks:

Send my quotation via: E-Mail Fax
Regular Mail

Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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