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  • Page 1 of 2

  • Personal Information

  • Which is you preferred phone?*
  • Format: (000) 000-0000.
  • Which is you preferred email?*
  • Is there a secondary applicant?
  • Format: (000) 000-0000.

  • Page 2 of 2

  • For Renters and Condo Policy

    if applying for Homeowners please skip to page 3. Renters and Condos can skip to page 4 after completing page 2.
  • Is the property currently insured?
  • Do you currently have pets or animals
  • Do they own any valuable jewelry, cameras, bikes, or fine art?
  • Portable electronics (Stuff like phones and laptops that are worth more than $1,500 in total)
  • Has the applicant been canceled, declined or nonrenewed including for non-payment within the past 5 years?
  • Security Devices, Check all that apply:
  • Does the applicant conduct any business on the premises?

  • Homeowners Policy

    Only for homeowners Policy. Skip to consent and submit tab for renters and condos.
  • Does the applicant conduct any business on the premises?
  • Does the applicant want replacement cost on the dwelling?
  • Does the applicant or anyone residing at the dwelling. Own, keep, or shelter an unacceptable dog? OR• own, keep, or shelter an animal that has caused harm?
  • Security Devices, Check all that apply:
  • Is there a secondary heat source in the dwelling?
  • Security Devices, Check all that apply:
  • Does any attached / detached garage or outbuilding contain a wood, solid fuel or portable kerosene heating device?
  • Is the dwelling a rowhouse or townhouse?
  • Purchase Date:
     - -
  • Has the roof of the dwelling been updated?
  • Does the applicant intend to pay the entire annual premium at this time?
  • Does the applicant or anyone residing in the home smoke?
  • Does the applicant also have an auto policy with the agency?
  • Is the property currently insured?
  • Has the applicant been canceled, declined or nonrenewed including for non-payment within the past 5 years?
  • Is there any existing damage, needed repairs or liability hazards to the Roof, Structure, Chimney, Foundation, Premises or Other Structures?
  • Is the dwelling under construction or renovation?
  • Is there a swimming pool with a depth of more than 2.5 feet on the premises?
  • Is there a trampoline on the premises?
  • Is the dwelling currently vacant?
  • Does the applicant or anyone residing at the dwelling:• own, keep, or shelter an unacceptable dog? OR• own, keep, or shelter an animal that has caused harm?
  • Does the applicant or anyone residing at the dwelling own, keep or shelter any unusual or exotic animals that would increase liability concerns?
  • Does the applicant belong to any of the following affinity groups? Check all that apply:

  • Authorization and Consent

    Please read the attestations below and select a response. Information given is used by JDH Solutions PLLC, for the purposes of assessing eligibility for your quoting, binding, claims, underwriting, investigating, and auditing.  Agree to continue application, Disagree if you do not wish to move forward with your application.
  • I authorize JDH Solutions PLLC to collect and use my personal information for the sole purposes for my personalized insurance quote and binding. All information I have submitted is true and accurate to the best of my knowledge and I have not in any way submitted false, inaccurate, or misleading information on this application or any application submitted on my behave or my company.  Any Person Who Knowingly and With Intent to Defraud Any Insurance Company or Another Person Files an Application for Insurance or Statement of Claim Containing Any Materially False Information or Conceals for The Purpose of Misleading Information Concerning Any Fact Material Thereto, Commits A Fraudulent Insurance Act, Which Is a Crime And Subjects The Person To Criminal And [Ny: Substantial) Civil Penal Ties. (Not Applicable in CO, FL, HI, MA, NE, OH, OK, OR VT. In DC, LA, ME, TN, VA and WA Insurance Benefits May Also Be Denied). In Florida, Any Person Who Knowingly and With Intent to Injure, Defraud, Or Deceive Any Insurer Files A Statement of Claim or An Application Containing Any False, Incomplete, Or Misleading Information Is Guilty of a Felony of The Third Degree.*
  • Date*
     - -
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  • Should be Empty: