Coverage Request Form
Agency:
Certificate #:
class="instructionText"> (#-###-##)
Mailing Address:
City:
State:
ZIP:
Building Name:
Bldg. Number:
County:
Select County...
Alachua (11)
Baker (52)
Bay (23)
Bradford (45)
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Lee (18)
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Levy (39)
Liberty (67)
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Not in Florida (99)
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Location Address:
City:
State:
ZIP:
Flood Zone:
A
A1
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A2
A20
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A3
A30
A4
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A99
AE
AH
AO
B
C
D
V
V1
V10
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V12
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V15
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V2
V20
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V28
V29
V3
V30
V4
V5
V6
V7
V8
V9
VE
VO
X
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Basement:
Yes
No
Inside City Limits:
Yes
No
Most Recent Construction Year:
Sq. Footage:
Occupancy:
Select Occupancy...
Educational
Office
Other
Penal
Recreational
Residential
Storage
If Other, provide description:
Sprinklered:
%
GPS with Tutorial:
(Use
https://maps.floridadisaster.org/GATOR/map.html
. 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:
Frame
Masonry
Semi Wind Resistive
Wind Resistive
Subtype:
If other, provide description:
ROOF SUPPORTS:
Type:
Frame
Masonry
Semi Wind Resistive
Wind Resistive
Subtype:
If other, provide description:
AMOUNT OF ACV INSURANCE:
Building: $
Contents: $
Rental: $
Replacement (Bldg Only): $
Is building owned by any Agency, Board or Bureau of the State of Florida?
Yes
No
Nearest Hydrant:
Feet
Distance to Ocean/Gulf:
Select Distance...
< = 1 MILE
> 1 MILE, < = 5 MILES
> 5 MILES, < = 10 MILES
> 10 MILES, < = 50 MILES
> 50 MILES, < = 100 MILES
> 100 MILES
(Miles)
Fire Department Name:
Fire Pump:
Yes
No
If yes, type:
Security:
(Indicate all that are applicable.)
Keypad/Keycard Entry
Cameras
Building Lock Down
Police Drive-By
Entry Security Station
Watchman:
FULL TIME WATCHMAN
PART TIME WATCHMAN
Protected Signaling Systems:
AUXILIARY
CENTRAL STATION
CLOSED CIRCUIT
LOCAL
PROPRIETARY
REMOTE STATION
Alarm Services:
AUTOMATIC FIRE ALARM
BUILDING TEMPERATURE
BURGLARY ALARM
COMPLETE PUMP
DOOR CIRCUIT ALARM
HEAT DETECTION
INFRARED ALARM
INTRUSION DETECTION
LOCAL ALARMS
LOW AIR PRESSURE
MANUAL
MANUAL FIRE ALARM SYSTEM
MANUAL PULL STATIONS
PUMP POWER FAILURE
PUMP RUNNING
REMOTE STATION
SMOKE DETECTORS
SMOKE DETECTORS - POLICE STATION
VALVE TAMPER
VALVE TAMPER AND WATER FLOW
WATER FLOW
OTHER
Alarm Systems:
AUXILIARY
CARBON DIOXIDE
CENTRAL STATION
CLOSED CIRCUIT
DRY CHEMICAL
FOAM EXTINGUISHING
HALON
LOCAL
PROPRIETARY
REMOTE STATION
WATER-MIST
Water Supply:
CITY AND PRIVATE SUPPLY
CITY SUPPLY
CITY WITH BOOSTER PUMP
COMBINED DOMESTIC FIRE PROTECTION SUPPLY
FIRE PUMP & TANK OR EQUIVALENT SUPPLY
NEARLY RELIABLE PUBLIC WATER SUPPLY OR EQUIVALENT
PRIVATE-COMBINED GRAVITY/PUMPING
PRIVATE-GRAVITY PUMP
PRIVATE-PUMPING SUPPLY
RELIABLE PUBLIC WATER SUPPLY OR EQUIVALENT
TWO INDEPENDENT & FULLY ADEQUATE SUPPLY
UNRELIABLE FIRE PUMP & TANK OR EQUIVALENT
UNRELIABLE PUBLIC SUPPLY
Smoke/Heat Alarms
Local Annunciator
Pull Stations
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