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 NameLast Name
Applicant DOB?*

MonthDayYear
Date
Is there a co-applicant?*

YesNo
Co-Applicant Name*

First NameLast Name
Co-Applicant DOB?*

MonthDayYear
Date
Will the property be owned by a corporation?*

YesNo
What is the corporation's name?*
Please provide corporation name as shown on property appraiser
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone 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 InsuredDP - Rental Property
What is the construction of the property?

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

9-12 Months5-8 Months0-4 Months
Do you require at least an annual lease?*

YesNo
Do you allow any form of short term rental?*

YesNo
What is the home type?*

Single FamilyTownhouseMobile HomeCondoMulti-Family
How many units in building?*
How is Mobile Home Situated?*

Non-Owned Private PropertyOwned Private PropertyMobile Home ParkSenior Mobile Home Park
Are you responsible for the exterior of the property and the roof?*

YesNo
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?*

YesNo
Alarms in the home?*

YesNo
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?*

YesNo
Has coverage on this property been cancelled, rejected, or non-renewed in the last three years?*

YesNo
Will the property be occupied within 30 days of effective date?*

YesNo
Do you allow tenants to have dogs?*

YesNo
What kind of animal?*
Include species and breed. (ex. a dog; chihuahua)
Pool on the property?*

YesNo
Pool Area Screened? OR Yard Entirely Fenced?*

YesNo
Are there currently any type of renovations or construction occurring on the property?*

YesNo
Was the home purchased through short-sale or foreclosure?*

YesNo
Does your home have any burglar bars installed?*

YesNo
Do the bars have quick release mechanisms?*

YesNo
Loss History
Has this property or any properties you've owned sustained in damage that resulted in a claim in the past 5 years?*

YesNo
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?*

YesNo
Year electrical was installed/updated?*
To your knowledge is your electrical panel made by Federal Pacific or Sylvania?*

YesNo
To your knowledge does your home contain any aluminum, cloth, or knob and tube wiring?*

YesNo
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