First & Last Name
Date of Birth (include month, day and year)
Phone number
Occupation
Email address
Address (#, street, unit #, city, state, zip and county)
Have you filed for bankruptcy within the last 7 years? Please Select Yes No
Who is your current homeowners insurance company?
Address of property to be insured
County of Property
Purpose of this property: Please Select Primary Residence Primary Residence with rental income Rental Property Vacation Home Secondary Residence
Is this property currently under construction? Please Select Yes No
What is your policy expiration date?
What is your ANNUAL homeowners premium?
For discount purposes, who is your current auto carrier and what is the current policy #?
Purchase Price of home
What is the market value of the property?
Mortgage Amount
Make this insurance payment part of your mortgage payment? Please Select Yes No
How many mortgages do you have on this home? Please Select 1 2 3 None
When is your closing date or when did you move in?
What is the distance to the nearest fire hydrant?
What is the distance to the nearest fire station?
What is the name of the closest Fire Department?
Is this fire department a paid or volunteer service? Please Select Paid Volunteer
Identify the type of features and systems you have in your home: Local Alarm (Fire and Burglar) Central Fire Central Burglar Sprinklers Gated Community Temperature Monitoring Back-up Generator Smoke/Fire Fire Extinguishers Dead Bolts Visible to neighbors None of the above
Does this property have circuit breakers? Please Select Yes No
Age of Home:
Home type: # of Families Please Select 1 2 3 4
How many occupants?
Construction Type: Please Select Frame Brick Masonry Hardi-Plank
What type of siding is on your home? (i.e. vinyl, wood, stucco, etc.)
Number of stories (not including basement)
Style of house (ranch, colonial, split, etc)
Overall square footage of living space.
How many bedrooms?
How many full bathrooms?
How many half bathrooms?
Do you have any specialty rooms (study, exercise) if so, please identify type.
Do you also have any of the following? (check all that apply) Decks Porches Patios Custom kitchens/baths Cathedral ceilings Fireplaces Attached Garage Detached Garage Central Air Jacuzzis None of the above
Your home’s inside walls are composed of? (i.e. sheetrock, plaster, block)
The inside walls of this property contain: paint wallpaper ceramic tile marble/granite paneling
The floors of this property contain: wood parquet ceramic tile marble/granite carpet
Garage Please Select No Garage detached garage attached, 1 car attached, 2 car attached, 3 car attached, 4 car attached, 5 car
Fireplace? Please Select None Yes, 1 Yes, 2 Yes, 3 Yes, 4
What type of roof does your home have?
Is your roof pitched or flat? Please Select Pitched Roof Flat Roof
Do you have any custom windows? If so, advise how many and type.
Basement None, on a slab Finished Unfinished Partially finished Partial basement
If you have a basement, what percent of the basement is finished?
If you have a basement, is it a walk-out basement? Please Select Yes No
Type of heat: Above ground oil tank Below ground oil tank Electric Gas Wood stove
Is their a fuel tank on this property? Please Select Yes No
What year was the wiring updated/renovated?
What year was the plumbing updated/renovated?
What year was the heating updated/renovated?
What is the age of the roof?
Regarding your exterior, please check all that apply: Above ground pool Inground pool Pool has a slide Pool has a diving board Pool is fenced Trampoline(s) on premises If required, I am willing to remove the trampoline(s) within 30 days None of the above
How many acres is your property?
Is this property undergoing renovations or any reconstruction? Please select Yes No
Is this property currently for sale? Please Select Yes No
Do you have any other structures on your property not mentioned here? Please describe.
Have you had any losses in the past 3 years? Please Select Yes No
Is this property within 2 miles of tidal water? Please Select Yes No
Have you had a foreclosure, repossession, bankruptcy, judgment or lien against you in the past 5 years? Please Select Yes No
In the past 5 years, have you been convicted of the crime of arson in any degree? Please Select Yes No
Are there any uncorrected fire or building code violations on this property? Please Select Yes No
Is there a lead paint hazard on this property? Please Select Yes No
If yes to losses, please advise on type of loss, date of loss and payments:
If you have pets, please advise on type of pet and breed. Please advise on any bite history
Would you like to have any jewelry, furs, fine arts or silverware insured also? If so, please advise on type and value below.
Do you have any full-time domestic workers, nannies or caretakers? If so please advise below.
If you live in an association, do you pay a maintenance fee? If so, please quote increased Loss Assessment Coverage. Please Select Yes No
Are you interested in obtaining quotes on higher limits of liability? Please Select Yes No
If yes to higher limits, please list the locations, # of vehicles and underlying limits:
List the names, dates of birth, driver license #’s and the underlying carriers for each youthful driver.
Do you also own any of the following? (check all that apply) Minibikes Mopeds Motorcycles Motorhomes Aircraft Snowmobiles Golfcarts None of the above
Regarding any owned watercraft, please identify the type, size of vessel and horsepower.
Did we miss anything? Include additional comments here.
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