| * = required |
| Name:* | |
| Phone Number:* | (xxx-xxx-xxxx) |
| Email Address:* | |
| Address: | |
| | |
| City: | |
| State: | |
| Zip: | |
| Date of Birth: | (mm/dd/yyyy) |
| Social Security Number: | |
| Is this a new policy: |
Yes
No |
| Who's your current insurer: | |
Current Policy
Expiration Date: | (mm/dd/yyyy) |
How Long Have You
Been Insured With
Your Current Company: | years |
Will you or do you
live on this property: |
Yes
No |
How much coverage do
you want on
your personal property: | $ |
| How much personal liability: |
$100,000
$300,000
$500,000
$1,000,000 |
| Deductible: |
$500
$750
$1,000
$2,000 |
| Number of Units: | |
| Number of Stories: | |
| Year Built: | (yyyy) |
| Approximate Square Feet: | |
| Number of Bathrooms: | |
Have you reported any claims
or losses to your
insurance company within the last 3 years: |
Yes
No |
| Type of Construction: |
Brick
Wood Frame
Cinder Block
Other |
| Roof Type: |
Composite Shingle
Tile
Wood Shingle
Other |
| Roof Age: | years |
| Burglar Alarm: |
Yes
No |
| Swimming Pool: |
Yes
No |
| Heating System: |
Forced Air
Electric
Boiler
Oil
Propane |
Number of gas or wood
fireplaces or stoves: | |
| Wiring Type: |
Copper
Aluminum
Unknown |
| Service Panel Type: |
Fuse Box
Circuit Breaker |
| Is this a New Purchase: |
Yes
No |
| Floor Type: |
Carpeting
Hardwood
Ceramic tile
Vinyl |
| Are There Any Decks: |
Yes
No |
| Deck Size: | Sq. Feet |
| Porch: |
Yes
No |
| Screened Porch: |
Yes
No |
| Porch Size: | Sq. Feet |
| Jacuzzi or Hot Tub: |
Yes
No |
| Skylights: |
Yes
No |
| Number of Skylights: | |
| Garage: |
Yes
No |
| Garage Size: | cars |
| Is There A Basement: |
Yes
No |
| Is Basement Finished: |
Yes
No |
| House Style: |
1 Story
1 1/2 Story
2 Story |
| Renovations: |
Yes
No |
| If Yes, Renovation Type: |
Heating
Electric
Plumbing |
| Laundry Room Location: |
Basement
First Floor
Second Floor or Above |
| Prior Insurance Claims: |
Yes
No |
| Central Air/Heat: |
Yes
No |
| Sprinklers: |
Yes
No |
| Value of Home: |
$ |
| Type of Residence: |
Single Family
Duplex
Townhouse
Row House
Condo
|
| Sub Structure: |
Slab on Ground
Open Foundation
Crawl Space
Piers
|
| Exterior Walls: |
Concrete Block
Aluminum Siding
Vinyl Siding
Brick
Stone
Stucco
|
For residents in coastal states:
To insure you get all your eligible discounts, please answer the following questions to the best of your knowledge. |
| Roof Wall Connection: |
Toe Nailed
Clips
Single Wraps
Double Wraps
Unknown
|
| Roof Level Attachment: |
Level A
Level B
Level C
Unknown
|
| Roof Covering: |
meets FBC 2001
meets SFBC 1994
Concrete Roof Deck
Unknown
|
| Window and Opening Protection: |
Intermediate
Hurricane Protection
None
|
| Secured Community: |
Yes
No |
| If YES to Secured Community, Access Type: |
Single Entry
24 hr Security
24 hr Manned Gate
Pass Key Entry
|
| Name of Builder: |
|
| Retired: |
Yes
No |
| Current Auto Insurer: |
|
|
