Applicant First Name
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Applicant Last Name
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Phone
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Email
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Occupation
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Employed or retired?
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Co Applicant (Required if there is one)
Co Applicant DOB
Co Applicant Phone
Co Applicant email
Property Address
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Mailing Address if Different from property address
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Home Usage
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Primary
Secondary
Rental
Other
How Many years at this address
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New Purchase
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Yes
No
Purchase Price
Closing / Purchase Date
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Accredited Builder
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Yes
No
Who Is your Current Carrier?
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Describe Current Coverage
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Reason for Shopping
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Rates
Have been Cancelled
Non Renewed
Other
If Losses claimed in the last 5 years, approximately how much were the claims?
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Year Built
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Stories?
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Bed Rooms / Baths?
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Heated Sq Feet
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Total Rooms
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Attached Structure
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Garage
Carport
Other
Out Buildings? If yes, value?
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Solar Panels
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Solar Panels (Quantity / Wattage / Value)
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Will you also Need a Flood Quote (bundling may benefit you)
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Yes
No
If Inspected in the last year was it 4 point or wind mitigation? What was the purpose?
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Porches (sq footage next field)
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Open
Closed
SQ FT Porches
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Patio (sq ft next field
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Open
Closed
Patio SQ FT
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Deck / FRAME Type
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Masonry
Wood
No Deck
Type of Siding
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Wood
Vinyl
Aluminum
Brick
Block
Stucco
Log
HardiBoard
Other
Foundation
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Slab
Crawl space
Other
Fireplace
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Yes
No
Roof Type
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Asphalt Shingles
Arct Shingles
Metal
Conct Tile
Other / Blended
Roof Shape
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Gabled
Flat
Hip
Roof Updated?
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yes
no
Roof Update Year?
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Age of Roof
HVAC Type
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Gas
Electric
Other
Cloth Wiring
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Yes
No
Plumbing
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Copper
Galvanized
PVC
PEX
Polybutylene
Other
Plumbing - Renovated or Replaced (year)
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Water Heater Replaced (year)
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Are you LESS than 5 miles away from a fire department?
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yes
no
How Close are you to a fire hydrant?
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Less than 500 Ft
Less than 1000 ft
More than 1000 ft
I am not certain
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*
Yes, I have an Alarm System
Yes, I have a monitored alarm system
Yes, I have a smoke detector
Yes, I have a fire extinguisher
Yes, I have a burglar alarm
Yes, I have a local system (Ring, etc)
Secured Community
Single Entry
Gated
Passkey Needed
Security Guard
Outdoor Recreation (Pool, trampoline, Jacuzzi) (select all that apply)
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In ground
above ground
slide
diving board
Fenced
Gated
screened enclosure
Jacuzzi / Hot Tub
Trampoline
Dogs (Breed & How Many?)
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Umbrella Policy (do you have recreational vehicles or rental properties) Describe please.
*
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