Department of Financial Services
Division of Risk Management
Coverage Request Form

Agency Name: Certificate #: (#-###-##)
Mailing Address: City: State:  Mailing ZIP:
Building Name: # of Stories Building: Building No.:
Address / Directions: Flood Zone:
City: County: Location ZIP: Inside City Limits?

Responding Fire Department If Other, provide description:
Occupancy If Other, provide description:

Exterior
Walls
Sprinkler System
  If Other, provide description:    

Roof Supports If Other, provide description:
Amounts of
Insurance 		Building:
$		 Contents:
$		 Trailer:
$		 Rental Value:
$
Ownership Is building owned by any Agency, Board or Bureau of the State of Florida?
If yes, give the following: Square Feet: Construction Date:

Requested By Name: Title:
Phone Number: Date:

*By placing your initials here, you are thereby signing this document with your signature.       Electronic Signature:

TRUST FUND USE ONLY
Building Fire Rate: Contents Fire Rate:
EC Rate: Fire Credit Sch: EC Credit Sch:
EZ Zone: Town Class: Chapter 284 and 287M F.S.
Insurance Effective Date:

electronic version (DI4-850)
(Revised 11/2005)