Clearwater Underwriters, Inc.

CBRA Application

	Applicant / Insured
Insured: (*)	Invalid Input
Mailing Address: (*)	Invalid Input
City, State Zip (*)	Invalid Input
Property Address (if different):	Invalid Input
City, State Zip	Invalid Input
Barrier Island Name:	Invalid Input
County	Invalid Input
	Mortgagee
First Mortgagee:	Invalid Input
Loan No:	Invalid Input
Address:	Invalid Input
City, State Zip	Invalid Input
Second Mortgagee:	Invalid Input
Loan No:	Invalid Input
Address:	Invalid Input
City, State Zip:	Invalid Input
	Agent
Agency Name: (*)	Invalid Input
Contact: (*)	Invalid Input
Email Address: (*)	Invalid Input
Address: (*)	Invalid Input
City, State Zip (*)	Invalid Input
Phone Number: (*)	Invalid Input
	Policy Info
Current CBRA Company:	Invalid Input
Policy Number:	Invalid Input
Any prior flood losses? (*)	Invalid Input
If you chose yes for prior flood loss, please provide the date and amount.	Invalid Input

	Underwriting
Occupancy: (*)	Invalid Input
If you chose Other for Occupancy, please describe:	Invalid Input
If Condo Assoc. or Hotel how many units:	Invalid Input
Construction (*)	Invalid Input
# of Stories:	Invalid Input
Basement: (*)	Invalid Input
Enclosure:	Invalid Input
Pre or Post-FIRM: (*)	Invalid Input
If Post-FIRM, elevation difference:	Invalid Input
Foundation: (*)	Invalid Input
Year Built: (*)	Invalid Input
NFIP Flood Zone: (*)	Invalid Input
Replacement Cost of Building: (*)	Invalid Input
Building Limits: (*)	Invalid Input
Requested Date of Coverage:	Invalid Input
Is property located in an eligible CBRA/OPA area?	Invalid Input
Is property located in a non-participating community:	Invalid Input
Distance from body of water:	Invalid Input
Type of body of water:	Invalid Input
Contact name for inspection:	Invalid Input
Contact phone number:	Invalid Input
Any additional remarks:	Invalid Input
Preferred Underwriter to work this risk: (*)	Invalid Input