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Dazet Insurance Group, LLC
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Flood quote request


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name *
Last Name *
Date of Birth *
/ /
Gender
Marital Status *
Spouse First Name
Spouse Last Name
Street *
City *
State *
ZIP / Postal Code *
Primary Phone Number *
E-Mail Address *
Alternate Phone Number
Do you currently have insurance?
If no, when did you last have insurance?
/ /
Current Insurance Provider
Current Premium
Current Policy End Date
/ /
Claims/Property Losses in Past 5 Years (Please Explain)
Do you rent or own your home?
Rental
Date of Original Purchase
/ /
Ownership *
Occupancy
Is home occupied?
Coverage Period
Building Type
Construction Type
Number of Stories
Number of Stories Including Basement
Square Footage *
Is home on permanent foundation?
Year of Last Major Construction
Roof Type
Year of Last Reroof
Garage
Amount Requested on Building Coverage
Amount Requested on Contents
Deductible Amount
Liability Limit
Property Damage Liability *
How many additional insureds are required?
Lein Holder Information
Bank/Lender *
Lien Holder Phone Number
Additional Comments
How did you hear about us?
Submission Validation
Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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9111 W Saint Bernard Hwy
Chalmette, LA 70043
Phone: 504.454.6424
504.883.5132

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