Form FEMA Form 517-1 FEMA Form 517-1 Agent Referral Program Enrollment Form

DEPARTMENT OF HOMELAND SECURITY
FEDERAL EMERGENCY MANAGEMENT AGENCY

NFIP AGENT REFERRAL
PROGRAM

NATIONAL FLOOD INSURANCE PROGRAM
AGENT SITE REGISTRATION

O.M.B. NO. 1660-0059
Expires, 2011

PAPERWORK BURDEN DISCLOSURE NOTICE
Public reporting burden for this form is estimated to average .O33 hour per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting the form. You are not required to respond
to this collection of information unless it displays a valid OMB control number. Send comments regarding the accuracy of this burden estimate and any
suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management
Agency, 500 C Street, SW, Washington, D.C. 20472, Paperwork Reduction Project (1660-0059). NOTE: Do not send your completed form to
this address.
The National Flood Insurance Program (NFIP) Agent Referral Program generates leads from people who want to buy flood insurance. Consumers call
the NFIP Call Center and request an agent, or log onto FloodSmart.gov and use the Agent Directory tool. To receive lead referrals, all you have to do
is complete this enrollment form and submit it to the NFIP. See blow for details. NOTE: if you are currently enrolled in the Agent Referral Program,
please use this form to update your contact information.
AGENT INFORMATION (Please print. Information must be legible to be entered in the program.).

Create A User ID

Password

Verify Password

Agent's First Name

Agent's Last Name

Agency Name

Address

City

State

Direct Phone Number

General Phone Number

Mobile Phone Number

Fax Number

E-Mail Address

Web Address

NFIP flood insurance written through these insurance companies.
At least one flood insurance company is required.

Zip Code

I'd like to receive periodic program updates, news,
and information from the NFIP

NRIP REFERRAL PROFILE
To create or update your profile online, simply fill out the form below. After you have completed the form, your contact information and training status
will be verified by a FloodSmart agent. Once approved, your information will be immediately available on FloodSmart.gov and leads will start to generate
through the NFIP Call Center. Agent approval may take up to 2 business days.
NOTE: Field marked with an asterisk (*) are required.
*Are you licensed to sell flood insurance nationally? NOTE: If you select YES, you
do not have to enter zip codes in the following question.

YES

NO

List all ZIP Codes in which you do business. Enter 2 or more digits with an asterisk to represent a group of ZIP Codes. Maximum 32 ZIP Codes.

FEMA Form 517-1 SEP 08

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NRIP REFERRAL PROFILE - continued

Residential

Specializations:

Commercial

Rental

Other

*Business Hours:

Sunday

am

TO

pm

Monday

am

TO

pm

Tuesday

am

TO

pm

Wednesday

am

TO

pm

Thursday

am

TO

pm

Friday

am

TO

pm

Saturday

am

TO

pm

*Business Time Zone:
Please enter and select one or more numbers to display on your Agent Profile. These number will be shared with prospective clients through
FloodSmart.gov and through the NFIP Call Center.
DISPLAY NUMBER
*Direct Phone Number:
General Phone Number:
Mobil Phone Number:
Fax Number:
*Agent Referral Program Status:

Active. I would like to receive customer referrals.
Inactive. I would like to postpone or cancel customer referrals.
Proof of Flood Insurance Training is required to remain active in the Agent Referral Program.
*Trained?

YES

NO

*Training Date

FEMA Form 512-1 SEP 08

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