Property Proposal Information Form
Aida Trevino-Wells Agency
Current Date
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Primary Insured Name
*
First Name
Last Name
Primary Insureds Date of Birth
*
-
Month
-
Day
Year
Date
Primary Insureds last 4 of SSN
*
Primary Insureds Gender
*
Please Select
Male
Female
X
Spouse/Significant Other Name
First Name
Last Name
Spouse/Significant Other's Date of Birth
-
Month
-
Day
Year
Date
Spouse/Significant Other's last 4 of SSN
Spouse/Significant Other's Gender
Please Select
Male
Female
X
Address of property to be insured
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When did you or when do you plan on moving into this address?
*
If you have lived at the above address for less than three years, what was your previous address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What year was the roof of the property last replaced?
*
What type of material is the roof?
*
(i.e.: Asphalt Comp, Concrete Tile, Metal, etc.)
What year was your furnace and/or AC last replaced?
*
What type of flooring is in property and what is the percentage of each?
*
(i.e.: Carpet 50%, Hardwood 25%, Tile 25%)
Is your basement finished?
*
Please Select
Yes
No
NA - no basement
Do you have any dogs on the property? If so, please provide their name, breed, age, weight and coloring. If you do not have any doges, please enter 'NA'.
*
On the property, is there any skateboard ramps, home based businesses, child/adult care, pool or trampoline? If yes, please provide details on each. If none of these items are on the property, please enter 'NA'.
*
Does the property generate power through solar panels or back up genterator?
*
Please Select
Yes
No
If the property generates power through solar panels, how many panels are installed?
Do you have any specialty items that needed individual so specific coverages?
*
Please Select
Yes - please contact me for details
Yes - but not looking for that now
No
Unsure - please contact me for details
Please upload any of your current insurance documents you feel comfortable sharing.
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Has anyone associated with the property been convicted of a felony?
*
Please Select
No
Yes
Unknown
Have you or the property had any claims filed in the last 5 years?
*
Please Select
No
Yes
Unknown - new purchase
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