Home Insurance Quote

Landlord Insurance Quote Sheet

Required Document for All New Business HO and DP Policies (Not designed for builder's risk or vacancy)
Basic Information
Applicant Name *

First Name Last Name
Applicant DOB? *

Month Day Year
Date
Is there a co-applicant? *

Yes No
Co-Applicant Name *

First Name Last Name
Co-Applicant DOB? *

Month Day Year
Date
Will the property be owned by a corporation? *

Yes No
What is the corporation's name? *
Please provide corporation name as shown on property appraiser
Property Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
E-mail *
example@example.com or N/A if no email
Determining Policy Form

Questions Used to Determine Policy Needed
What will be the purpose of this property? *

HO - Residence of Insured DP - Rental Property
What is the construction of the property?

Masonry - Block or Concrete Frame - Wood or Aluminum
How many months a year do you reside at this property? *

9-12 Months 5-8 Months 0-4 Months
Do you require at least an annual lease? *

Yes No
Do you allow any form of short term rental? *

Yes No
What is the home type? *

Single Family Townhouse Mobile Home Condo Multi-Family
How many units in building? *
How is Mobile Home Situated? *

Non-Owned Private Property Owned Private Property Mobile Home Park Senior Mobile Home Park
Are you responsible for the exterior of the property and the roof? *

Yes No
Make of the Home? *
Ex. Fleetwood or Palm Harbor if unsure notate.
Square Footage of Mobile Home *
Customer can also provide length and width
Serial Number of the Home?
Typically located in kitchen cabinet or master closet if unsure notate.
Age of the Mobile Home? *
Structures of the Mobile Home? *
Ex, Attached Sunroom 400 square foot worth 5,000 or unattached shed that is 350 square feet worth 3000. If no other structures are provided put N/A in the field.
Discount Questions!

The best part of the form!
Do you have a wind mitigation form? *

Yes No
Alarms in the home? *

Yes No
Specify Further? *
Please note monitored alarms can be ONLY burglary, ONLY fire, or BOTH. Local can simply be smoke detectors or un-monitored alarm.
Underwriting Questions

These are some of the most common underwriting related questions that arise that can affect eligibility
Is there any existing damage or debris on the property? *

Yes No
Has coverage on this property been cancelled, rejected, or non-renewed in the last three years? *

Yes No
Will the property be occupied within 30 days of effective date? *

Yes No
Do you allow tenants to have dogs? *

Yes No
What kind of animal? *
Include species and breed. (ex. a dog; chihuahua)
Pool on the property? *

Yes No
Pool Area Screened? OR Yard Entirely Fenced? *

Yes No
Are there currently any type of renovations or construction occurring on the property? *

Yes No
Was the home purchased through short-sale or foreclosure? *

Yes No
Does your home have any burglar bars installed? *

Yes No
Do the bars have quick release mechanisms? *

Yes No
Loss History
Has this property or any properties you've owned sustained in damage that resulted in a claim in the past 5 years? *

Yes No
Please detail all losses with locations, dates, amounts, type of damage, and status of claim. *
Ex, Water Damage 5/10/2015 $30,000 Paid Out Claim is Closed.
Update Questions

Questions used to determine age of major systems in home for discount and eligibility purposes.
Year Roof was Installed/updated? *
Roof Type *
Please Describe *
Year HVAC was installed/updated? *
Year plumbing was installed/updated? *
Are you aware of the presence of Polyethylene in your home? *

Yes No
Year electrical was installed/updated? *
To your knowledge is your electrical panel made by Federal Pacific or Sylvania? *

Yes No
To your knowledge does your home contain any aluminum, cloth, or knob and tube wiring? *

Yes No
What year is the house built in?
Are there underground fuel tanks?
Should be Empty:

Landlord Insurance Quote Sheet

Basic Information

Determining Policy Form

Discount Questions!

Underwriting Questions

Loss History

Update Questions