Homeowners Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Single
Married
Separated
Divorced
Widowed
Occupation
*
Co-Applicant Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Occupation
Dwelling Location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Foundation Type
*
Roof Type
*
Any updates to heating, plumbing, wiring, and roof?
*
Distance to hydrant
*
Distance to Fire Station
*
Square Footage
*
Purchase Date/Year
*
Number of Families
*
Circuit Breakers or Fuses
*
Do you have any fireplaces? (If so how many and what type of fireplace is it?)
*
Do you have a Protective Device?
*
Central
Local
Direct
Primary heat type
*
Knob & Tube Or Aluminum Wiring
*
yes
no
Dwelling Location
*
Within City Limits
Within Fire District
Within Protective Suburbs
Is the dwelling occupied daily?
*
Prior Carrier
*
Prior Carrier Expiration Date
*
-
Month
-
Day
Year
Date
Payment Type
*
Full Pay
Automatic EFT
Automatic Card
Bill by mail
Any farming or other business conducted on premesis?
*
yes
no
Any residence employees?
*
yes
no
Any flooding, brush, forest fire hazard, landslide, etc?
*
yes
no
Any other residence owned, occupied, or rented?
*
yes
no
Any other insurance with this company?
*
yes
no
Any coverage declined, cancelled, or non-renewed during the last 5 years?
*
yes
no
Has applicant had a foreclosure, repossession, bankruptcy, judgement or lien during the past 5 years?
*
yes
no
Are there any animals or exotic pets kept on premises?
*
yes
no
Distance to Tidal Water:
*
Miles
Feet
Is property situated on more than 5 acres?
*
yes
no
If yes, describe land use
Does applicant own any recreational vehicles?
*
yes
no
Is building retrofitted for earthquake?
*
yes
no
During the last 5 years has any applicant been indicted for or convicted of any degree of crime of fraud, bribery, arson, or any other arson-related crime in connection with this or any other property?
*
yes
no
If rented, is there manager on site?
*
yes
no
Not Applicable
If rented, is there a security attendant?
*
yes
no
Not Applicable
If rented, is the building entrance locked?
*
yes
no
Any uncorrected fire or building code violations?
*
yes
no
Is the house for sale?
*
yes
no
Is the property within 300 ft of a commercial or non-residential property?
*
yes
no
Is there a trampoline on premesis?
*
yes
no
Was the structure originally built for other than a private residence and then converted?
*
yes
no
Any lead paint hazard?
*
yes
no
If a fuel oil tank is on premesis, has other insurance been obtained for the tank?
*
yes
no
Loss History (Date, Type,Description, Amount)
*
Additional Interest (Name, Address, loan number)
*
Submit
Should be Empty: