Page 1 of 2
Personal Information
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which is you preferred phone?
*
Cell Phone
Home Phone
Phone Number
Which is you preferred email?
*
Personal Email
Work Email
Personal email
*
example@example.com
Date of Birth
Upload a photo of your state issued identification.
*
Is there a secondary applicant?
Yes
No
Name
First Name
Last Name
Phone Number
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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.
Type of Policy
Please Select
Homeowner
Renters
Condo
Mobile Home
Is the property currently insured?
Yes
No
Do you currently have pets or animals
Yes
No
Do they own any valuable jewelry, cameras, bikes, or fine art?
Yes
No
Portable electronics (Stuff like phones and laptops that are worth more than $1,500 in total)
Yes
No
Has the applicant been canceled, declined or nonrenewed including for non-payment within the past 5 years?
Yes
No
Complex / Owners Name
Number of units in building?
What kind of building do they live in?
Please Select
Single-Family
Multi Family
Townhouse
Apartment
Amount of personal property coverage:
Security Devices, Check all that apply:
Deadbolt
Smoke detector
Fire extinguisher
Carbon monoxide detector
Bars on windows and doors
Central fire alarm
Sprinkler
Burglar alarm
Home security
How many people not related to the applicant live in the unit?
Does the applicant conduct any business on the premises?
Yes
No
Amount of Property Coverage:
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Homeowners Policy
Only for homeowners Policy. Skip to consent and submit tab for renters and condos.
Current Value of home excluding the land.
Does the applicant conduct any business on the premises?
Yes
No
Amount of personal property coverage:
Construction Type
Please Select
Frame
Brick / Masonry
Venner Masonry
Hardi Plank
Fire Resistive
Other
Does the applicant want replacement cost on the dwelling?
Yes
No
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?
Yes
No
Security Devices, Check all that apply:
Deadbolt
Smoke detector
Fire extinguisher
Carbon monoxide detector
Bars on windows and doors
Central fire alarm
Sprinkler
Burglar alarm
Home security
Current Home Value
Year dwelling was built:
Dwelling Type
Please Select
Traditional Site Built Home
Manufactured / Mobile Home
Adobe Home
Condo
Dome Home
Earth Home
Log Home
Metal Home
Modular Home
Straw Home
Other
Construction Type:
Please Select
Frame
Brick/Masonry (51% or more)
Masonry Veneer (51% or more)
Hardi Plank (51% or more)
Fire Resistive (51% or more)
Other
Foundation Type:
Please Select
Basement
Slab
Closed Crawl Space
Raised Pier and Beam / Open - Height 2 Feet or Lower
Raised Pier and Beam / Open - Height More Than 2 Feet
Wood
Other
Dwelling Use
Please Select
Primary
Landlord / Rental
Secondary / Seasonal
Vacant / Unoccupied
Vacation / Short-term Rental
Number of separate living units:
Please Select
Single family dwelling
Duplex family dwelling
Triplex family dwelling
Fourplex family dwelling
Five or more family dwelling
Primary Heat Source:
Please Select
Furnace (forced air, radiant and central air)
Electric Baseboard
Heat Pump (geothermal and air-source)
Space Heater - permanent
Space Heater - portable
Boiler (steam and hot water)
Fireplace (including inserts)
Wood stove (including free standing fireplaces)
Other
None
Type of Fuel:
Please Select
Natural Gas
Propane (including LPG)
Oil
Electricity with utility company (grid)
Electricity - solar, wind or generators
Wood (including pellet and corn)
Coal
Kerosene
Other
Is there a secondary heat source in the dwelling?
Yes
No
Secondary Heat Source:
Please Select
Furnace (forced air, radiant and central air)
Electric Baseboard
Heat Pump (geothermal and air-source)
Space Heater - permanent
Space Heater - portable
Boiler (steam and hot water)
Fireplace (including inserts)
Wood stove (including free standing fireplaces)
Other
None
Second Type of Fuel:
Please Select
Natural Gas
Propane (including LPG)
Oil
Electricity with utility company (grid)
Electricity - solar, wind or generators
Wood (including pellet and corn)
Coal
Kerosene
Other
Security Devices, Check all that apply:
Deadbolt
Smoke detector
Fire extinguisher
Carbon monoxide detector
Bars on windows and doors
Central fire alarm
Sprinkler
Burglar alarm
Home security
Does any attached / detached garage or outbuilding contain a wood, solid fuel or portable kerosene heating device?
Yes
No
Number of residential dwellings on the same premises: Guest Homes, Duplex, etc
Hail Resistive Roof Classification:
Please Select
1
2
3
4
Is the dwelling a rowhouse or townhouse?
Yes
No
Total Square Footage: Total Living Space only
Purchase Date:
-
Month
-
Day
Year
Date
Roof Material:
Please Select
Asphalt / Composition Shingle
Wood
Metal - Steel / Aluminum / Copper
Slate
Tile - Concrete / Clay
Wood Shake / Shingle
Roof over Woodshake / Shingle
Unknown
Other
Has the roof of the dwelling been updated?
Yes
No
Does the applicant intend to pay the entire annual premium at this time?
Yes
No
Does the applicant or anyone residing in the home smoke?
Yes
No
Does the applicant also have an auto policy with the agency?
Yes
No
Is the property currently insured?
Yes
No
Has the applicant been canceled, declined or nonrenewed including for non-payment within the past 5 years?
Yes
No
Is there any existing damage, needed repairs or liability hazards to the Roof, Structure, Chimney, Foundation, Premises or Other Structures?
Yes
No
Is the dwelling under construction or renovation?
Yes
No
Is there a swimming pool with a depth of more than 2.5 feet on the premises?
Yes
No
If yes Pool Information
Please Select
Fence/Pool Height 4ft or Higher
Fence/Pool Height Less than 4ft
Other
Unfenced or Not Fully Enclosed
Is there a trampoline on the premises?
Yes
No
Is the dwelling currently vacant?
Yes
No
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?
Yes
No
Does the applicant or anyone residing at the dwelling own, keep or shelter any unusual or exotic animals that would increase liability concerns?
Yes
No
Does the applicant belong to any of the following affinity groups? Check all that apply:
Armed Forces Insurance
USAA
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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.
*
Agree
Disagree
Signature
*
Date
*
-
Month
-
Day
Year
Date
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