Sales Call Backs

Referring Agency
Referring Agent Name

First NameLast Name
Agent Email
example@example.com
Agent Phone Number

Area CodePhone Number
Client Name being referred

First NameLast Name

What is the policy type?

Homeowners (owner occupied)Renter (you lease the home)Condominium Owner (owner occupied condo or town home)Condominium Rental (rental to others condo or town home)Mobile Home (owner occupied)Dwelling Fire ( you are the landlord)
Requested effective date*

MonthDayYear
Date
How they would like documents sent?*

Esign,FaxEmail PDF
Applicant's Name*

First NameMiddle NameLast Name
Phone Number*
(###) ###-####
Email*
example@example.com
Applicant's Social Security
000112222 - *Do not use dashes
Applicant's Date of Birth*

MonthDayYear
Date
Applicant's Occupation*
What is your marital status?*

SingleMarried (must add spouse as co-applicant)
Is there a Co-Applicant?*

YesNo
Co-Applicant's Name*

First NameMiddle InitialLast Name
Phone Number (of Co-Applicant)*
(###) ###-####
Relationship status with main applicant.*
Husband, wife, sibling, parent, etc..
Co-Applicant's Email*
example@example.com
Co-Applicant's Social Security
000112222 - *Do not use dashes
Co-Applicant's Date of Birth*

MonthDayYear
Date
Co-Applicant's Occupation*
What is your marital status?*

SingleMarried

Property Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the mailing address different than the property address?*

NoYes (pls speciify below)
Mailing/Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
How many years have you lived at the address?*

Under 3 yearsMore than 3 years
Previous Property Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is the home in the name of an LLC?*

YesNo
Please list the name and type of trust.*
Is the home in the name of an LLC?
How is the home occupancy?*

Primary (9 or more months)Secondary (8-4 months)Seasonal(4 or less months),
Is it a Rental property (Rents to other)*

YesNo
Which months are the home occupied?*

JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Who is the home occupied by?*

InsuredTenant
What was the date occupied?*

MonthDayYear
Date
What is the number of occupants?*
What rental term do you have for your home?*

NoneDailyWeeklyMonthlyAnnually
Is your home a short term rental?*

Yes,NoN/A
Is the property centrally monitored by an alarm company?*

BurglarFireNone
Is the home gated?*

YesNo
Is the home in a single entry community?*

YesNo
Is this a new purchase or do you have prior insurance?*

New PurchasePrior InsuranceNo Current Insurance
Will you have a mortgage*

YesNo
Please provide your mortgage brokers: Name and contact information *
John Jones, ABC Mortgage (123) 678-4567
Would you like us to cancel your current insurance?*

YesNo
Prior Insurance Carrier*
Prior policy number
What was the purchase price of the home?*
What was the purchase date?*

MonthDayYear
Date

Has your home ever been foreclosed on?*

YesNo
Have you ever filed for bankruptcy?*
Have you filed any claims on any home in the last 5 years?*

YesNo
If any claims were filed - Provide date of loss, amount collected, and cause of damage for each claim
Do you have a mortgage holder?*

YesNo
Please list the name and loan number of the mortgage holder*
What is the square footage of your home?*
What is the year built on your home?*
What construction type is your home?*

MasonryFrameBrick
What kind of foundation does your home have?*

SlabCrawlspaceStiltsPilings
What year was your roof last replaced?*
What type of roof do you have?*

ShingleTileMetalOther
Did you have 4 point within the last year?*

YesNo
Do you have a wind mitigation within the last 5 years?*

YesNo
How many acres does your home sit on?*

Less than 2 acres2-5 acres,Over 5 acres

Are you within 1000 ft of a fire hydrant?*

YesNo
Are you within 5 miles of a fire station?*

YesNo
Are you on city or well water?*

CityWell
Do you have flood insurance?*

YesNo
Do you have any dog on the property?*

YesNo
If you have dogs, list breed(s)*
Please list all other animals in the home.*
Has your dog bitten anyone?*

YesNoNo dog
Do you have bars on your windows?*

YesNo
If so are they quick release?*

YesNoNo window bars
Do you have a pool?*

YesNo
Is your yard fenced?*

YesNo
Do you have a screen enclosure?*

YesNo
Does your pool have a diving board?*

YesNoNo pool
Does your pool have a pool slide?*

YesNoNo pool
Do you have a trampoline?*

YesNo

Do you run a business on premise?*

YesNo
Does your business have foot traffic to your home?*

YesNoNo business
Are there any ongoing renovations in the home?*

YesNo
Please list all active home renovations and their estimated completion date.*
How many stories is your home?*

123+
Do you have Solar Electric panels?*

YesNo
How many solar panels do you have?*
How many Kilowatts per hour are the Solar Panels?*
What kind of solar panels do you have?*

ElectricPoolN/A
Has your electric been updated?*

YesNo
What year was your electric updated?*

MonthDayYear
Date
Has your plumbing been updated (excluding the water heater)?*

YesNo
When was the plumbing updated (water heater)?*

MonthDayYear
Date
Has your HVAC been updated?*

YesNo
When was the HVAC system last updated?*

MonthDayYear
Date
Has your Water Heater been replaced?*

YesNo
When was your water heater replaced?*

MonthDayYear
Date
Has a new electrical panel been installed?*

YesNo
Please attach any: Wind Mitigation & 4 Point Inspections, Roof Permits, and/or Claims Information & Photos

Browse Files
WM, 4PT, Roof permits, Claims information Cancelof
Please list any important notes about the property.
I hereby acknowledge that by completing this online application questionnaire it is my intent to place coverage with a Regency Insurance/ Hilb Group carrier. The information I have submitted is accurate and true to the best of my knowledge. I also understand that by completing this online application questionnaire that this is not a guarantee of coverage, binder of coverage or confirmation that the property mentioned above will have coverage submitted. The information collected will be used as a tool for my agent to complete the necessary application with the new insurance carrier. I also acknowledge that I will receive a formal application to sign once its available and will receive confirmation of coverage once bound in writing from the insurance carrier.*

I confirm and YES you may proceed
Personal information about you may be collected from sources other than you in connection with this application and subsequent renewals. A credit report or score may be requested for underwriting or rating purposes. We may also obtain information about your credit history, your loss history and the loss history of the property proposed for coverage. Such information, as well as other personal and privileged information collected by us or our agents may, in certain circumstances, be disclosed to third parties, such as actuaries, underwriting consultants, and reinsurance brokers without your authorization, as permitted or required by law. A more detailed description of your rights regarding such information is available upon request.*

I confirm and YES you may proceed
You may be contacted by the insurance company to perform an additional interior/exterior inspection. This is different from any other inspections required or requested already from us. Since this inspection confirms eligibility, failure to complete this may result in cancellation of the policy. This inspection is complimentary to you as it is at the request of the insurance company. These inspections are often preformed by a third party and if needed they reach out to coordinate. If its only an exterior inspection, they may do an unscheduled visit on your property. Agreeing to place coverage grants permission for them to enforce their right to inspect the property*

I confirm and YES you may proceed
Should be Empty: