Auto + Home Ins. Purl (do not use)

Auto + Home Ins. Purl

This Auto + Home PURL is used to collect risk information for the purpose of quoting. Do not give or share with clients, in house use ONLY.

Completed By:

Agency Name*

enter agency prefix

Producer Names*

Assigned PURL*

LOB

For Edit Submission

Date*

Date

Time*

:HourMinutesAM/PM Option

How did you hear about us?*

Referred by:*

If known otherwise type Unknown

Notes:

Prior Ins. Policy Info:

Prior Carrier*

Name of Carrier

When does the policy expire

enter the exp/renewal date

First Applicant:

First & Last Name*

as listed on driver license

Will be listed as Driver? (1st applicant)*

Reason for Exclusion*

Explain why Excluded:*

Applicant Phone Number:

Gather if not in client file already

Applicant Email Address:

Gather if not in client file already

Birthdate*

Date

Gender:*

Marital Status:*

Driver License Number*

License State*

Type of Driver License

Class M Endorsed on License

Years Operating Experience

Experience of Motorcycle / ATV Riding

Employment Status*

Occupation / Job Title*

Example: Science or Engineering Degree

Self-Employed?*

Nature of work/business (applicant 1)*

Address of Business/Employer (applicant 1)*

Address of School/College*

Street Address Line 2

Good Student (Discount)*

Must have 3.0 or better GPA with 12 Units or More

Second Applicant:

First & Last Name (2nd applicant)*

as listed on driver license

Will be listed as Driver? (2nd applicant)*

Relationship to First Named Insured:*

Relationship (2nd app)

Reason for Exclusion*

Explain why Excluded:*

Birthdate*

Date

Gender:*

Gender (2nd app)

Marital Status:*

Marital (2nd app)

Driver License Number*

License State*

Type of Driver License

Class M Endorsed on License

Years Operating Experience

Experience of Motorcycle / ATV Riding

Employment Status*

Occupation / Job Title*

Example: Science or Engineering Degree

Self-Employed?*

Nature of work/business (applicant 2)*

Address of Business/Employer (applicant 2)*

Street Address Line 2

Address of School/College*

Street Address Line 2

Good Student (Discount)*

Must have 3.0 or better GPA with 12 Units or More

Applicant Address:

Garaging Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address Type*

Address (map it)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Add Driver? (1st driver)*

First & Last Name (1st driver)*

as listed on driver license

Relationship to First Named Insured (1st driver)*

Birthdate (1st driver)*

Date

Gender (1st driver)*

gender 1st driver (map to pdf)

Marital Status (1st driver)*

Driver License Number (1st driver)*

License State (1st driver)*

Type of Driver License (1st driver)

Class M Endorsed on License

Years Operating Experience (1st driver)

Experience of Motorcycle / ATV Riding

Employment Status (1st driver)*

Occupation / Job Title (1st driver)*

Example: Science or Engineering Degree

Self-Employed? (1st driver)*

Nature of work/business (1st driver)*

Address of Business/Employer (1st driver)*

Street Address Line 2

Address of School/College (1st driver)*

Street Address Line 2

Good Student (Discount) (1st driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (2nd driver)*

First & Last Name (2nd driver)*

as listed on driver license

Relationship to First Named Insured (2nd driver)*

Birthdate (2nd driver)*

Date

Gender (2nd driver)*

gender 2nd driver (map to pdf)

Marital Status (2nd driver)*

Driver License Number (2nd driver)*

License State (2nd driver)*

Type of Driver License (2nd driver)

Class M Endorsed on License

Years Operating Experience (2nd driver)

Experience of Motorcycle / ATV Riding

Employment Status (2nd driver)*

Occupation / Job Title (2nd driver)*

Example: Science or Engineering Degree

Self-Employed? (2nd driver)*

Nature of work/business (2nd driver)*

Address of Business/Employer (2nd driver)*

Street Address Line 2

Address of School/College (2nd driver)*

Street Address Line 2

Good Student (Discount) (2nd driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (3rd driver)*

First & Last Name (3rd driver)*

as listed on driver license

Relationship to First Named Insured (3rd driver)*

Birthdate (3rd driver)*

Date

Gender (3rd driver)*

gender 3rd driver (map to pdf)

Marital Status:*

Driver License Number (3rd driver)*

License State (3rd driver)*

Type of License (3rd driver)

Class M Endorsed on License

Years Operating Experience (3rd driver)

Experience of Motorcycle / ATV Riding

Employment Status (3rd driver)*

Occupation / Job Title (3rd driver)*

Example: Science or Engineering Degree

Self-Employed? (3rd driver)*

Nature of work/business (3rd driver)*

Address of Business/Employer (3rd driver)*

Street Address Line 2

Address of School/College (3rd driver)*

Street Address Line 2

Good Student (Discount) (3rd driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (4th driver)*

First & Last Name (4th driver)*

as listed on driver license

Relationship to First Named Insured (4th driver)*

Birthdate (4th driver)*

Date

Gender (4th driver)*

gender 4th driver (map to pdf)

Marital Status:*

Driver License Number (4th driver)*

License State (4th driver)*

Type of Driver License (4th driver)

Class M Endorsed on License

Years Operating Experience (4th driver)

Experience of Motorcycle / ATV Riding

Employment Status (4th driver)*

Occupation / Job Title (4th driver)*

Example: Science or Engineering Degree

Self-Employed? (4th driver)*

Nature of work/business (4th driver)*

Address of Business/Employer (4th driver)*

Street Address Line 2

Address of School/College (4th driver)*

Street Address Line 2

Good Student (Discount) (4th driver)*

Must have 3.0 or better GPA with 12 Units or More

Add Another Driver? (5th driver)*

First & Last Name (5th driver)*

as listed on driver license

Relationship to First Named Insured (5th driver)*

Birthdate (5th driver)*

Date

Gender (5th driver)*

gender 5th driver (map to pdf)

Marital Status:*

Driver License Number (5th driver)*

License State (5th driver)*

Type of Driver License (5th driver)

Class M Endorsed on License

Years Operating Experience (5th driver)

Experience of Motorcycle / ATV Riding

Employment Status (5th driver)*

Occupation / Job Title (5th driver)*

Example: Science or Engineering Degree

Self-Employed? (5th driver)*

Nature of work/business (5th driver)*

Address of Business/Employer (5th driver)*

Street Address Line 2

Address of School/College (5th driver)*

Street Address Line 2

Good Student (Discount) (5th driver)*

Must have 3.0 or better GPA with 12 Units or More

Policy Coverage:

Collect Policy Coverage Info now*

YesNo (client will email/text us the info)

Liability (Bodily Injury)

Liability (Property Damage)

Uninsured Motorist (Bodily Injury)

Medical Payments

Limit per accident

Vehicles on Policy:

Vehicle 1 Type*

Note: Since this travel trailer is pulled by a vehicle then it only needs physical damage coverage (Comp & Collision). The Policy coverage above (Liability and Uninsured Motorist and medical) will already be given by the vehilcle that is being used to tow this trailer.

Vehicle 1 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 1 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 1 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 1)

Towing and labor

Do you want to add a 2nd vehicle?

Vehicle 2 Type

Vehicle 2 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 2 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 2 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 2)

Towing and labor

Do you want to add a 3rd vehicle?

Vehicle 3 Type

Vehicle 3 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 3 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 3 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 3)

Towing and labor

Do you want to add a 4th vehicle?

Vehicle 4 Type

Vehicle 4 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 4 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 4 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance (vehicle 4)

Towing and labor

Do you want to add a 5th vehicle?

Vehicle 5 Type

Vehicle 5 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 5 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 5 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance

Towing and labor

Do you want to add a 6th vehicle?

Vehicle 6 Type

Vehicle 6 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 6 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 6 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance

Towing and labor

Do you want to add a 7th vehicle?

Vehicle 7 Type

Vehicle 7 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 7 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 7 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance

Towing and labor

Do you want to add a 8th vehicle?

Vehicle 8 Type

Vehicle 8 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Collector / Classic Car Questions:

Is the vehicle stored in a Private Garage/Barn/Pole Building?*

Where is the vehicle stored?*

How long have you owned this vehicle?*

Modification Type*

Custom Equipment Coverage

Enter the dollar amount of equipment

Motorcycle Questions:

Vehicle 8 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Ownership Type*

Who is Registered Owner*

Name*

Name of person who owns it.

Other Person/Company*

How is vehicle used*

Motorcycle Title*

Has Motorcycle been converted to a Trike*

Any Existing Damage*

Describe the Damage in Full*

Storage*

Motor Home Questions:

Vehicle 8 - Enter VIN and Verify*

(Vehicle Identification Number - 17 digits)

VIN Verified Successfully*

Estimated Cash Value (KBB)

verify the value thru KBB

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Odometer:*

Annual Miles*

Travel Trailer Questions:

Type of Trailers*

Trailer Length (feet)*

Estimated Cash Value (KBB)*

All Terrain Vehicle (ATV) / Snowmobile Questions:

Year of Vehicle*

Vehicle Make*

Vehicle Model*

Purchased Date

Estimated Cash Value (KBB)

Annual Miles*

Please Specify the Usage for this Vehicle*

Physical Damage Coverage (Full Coverage):

Quote Physical Damage for this vehicle*

Comprehensive Deductible)*

Collision Deductible*

Car Rental Coverage*

Cannot be purchased without collision

Roadside Assistance

Towing and labor

Would you like to collect the information for the home now

YesNo

General Policy Information:

How is the property titled?*

N/A for (Renters Ins - HO4 Policy)

Complete Name of Entity:

Enter complete name of Trust, LLC, Corporation or other

Describe your Home*

How will this home be used?*

How will this home be rented?*

How is this Condo/Town Home be used*

How is this Condo/Town Home rented?*

How is this Manufactured/Mobile Home used*

How is this Manufactured/Mobile Home rented*

Will this be a new purchase?*

Is the client buying this home now

Prior Carrier

Expiration Date

Name of Carrier

Underwriting Questions:

Section - Underwriting Questions for 1-4 Units

Is the Roof in poor condition or near end of life

YesNo

Is it a Woodshake Roof

YesNo

Is the primary heating system powered by other than natural gas and/or electric

YesNo

How is it powered

Is the electrical system on fuses

YesNo

Is the home under construction

YesNo

Will construction be completed before the effective date of the new policy

YesNo

Does the home have a Post and Pier Foundation

YesNo

Is there a Trampoline on premises?

YesNo

Anchored to the ground and netted

YesNo

Are there any farm animals

YesNo

How many types of farm animals

1324

1st Farm Animal type*

How Many*

2nd Farm Animal type*

How Many*

3rd Farm Animal type*

How Many*

4th Farm Animal type*

How Many*

Is there a swimming pool on the premises

YesNo

Does it have any of the following

Diving BoardWaterslideNone

Is the Property currently for sale or planned to be sold in the next 6 months? (By the applicant)*

YesNo

Is your current/prior policy being canceled for any reason

YesNo

Explain Why*

Are there Dogs on the premises

YesNo

Number of dogs

1324

1 - What is the Specific Dog Breed

2 - What is the Specific Dog Breed

3 - What is the Specific Dog Breed

4 - What is the Specific Dog Breed

Section - Underwriting Questions for Condo / Townhome requiring HO6 Policy

Is your current/prior policy being canceled for any reason

YesNo

Explain Why*

Are there Dogs on the premises

YesNo

Number of dogs

1324

1 - What is the Specific Dog Breed

2 - What is the Specific Dog Breed

3 - What is the Specific Dog Breed

4 - What is the Specific Dog Breed

Section - Underwriting Questions for Mobile / Manufactured Homes

Is the Roof in poor condition or near end of life

YesNo

Is the primary heating system powered by other than natural gas and/or electric

YesNo

How is it powered

Are there any farm animals

YesNo

How many types of farm animals

1324

1st Farm Animal type*

How Many*

2nd Farm Animal type*

How Many*

3rd Farm Animal type*

How Many*

4th Farm Animal type*

How Many*

Is your current/prior policy being canceled for any reason

YesNo

Explain Why*

Are there Dogs on the premises

YesNo

Number of dogs

1324

1 - What is the Specific Dog Breed

2 - What is the Specific Dog Breed

3 - What is the Specific Dog Breed

4 - What is the Specific Dog Breed

Section - Underwriting Questions for Renters requiring an HO4 Policy

Is your current/prior policy being canceled for any reason

YesNo

Explain Why*

Are there Dogs on the premises

YesNo

Number of dogs

1324

1 - What is the Specific Dog Breed

2 - What is the Specific Dog Breed

3 - What is the Specific Dog Breed

4 - What is the Specific Dog Breed

Policy Coverage:

CompleteSkip

Section: (For buildings 1-4 Units)

Dwelling Coverage*

Coverage A Limit

Detached Structure*

Coverage B Limit

Personal Property*

Coverage C Limit

Loss of Use / Loss of Rents*

Coverage D Limit

Personal Liability*

Coverage E Limit

Medical Payments*

Coverage F Limit

Water Backup / Sewer Backup*

Ordinance of Law Coverage*

Identity Theft Coverage*

Personal Injury*

Scheduled Personal Property*

Put "0" (zero) for items not required*

Notes

Section: (For Condo or Townhome Requiring an HO6 Policy)

Dwelling Coverage*

Coverage A Limit

Personal Property*

Coverage C Limit

Loss of Use / Loss of Rents*

Coverage D Limit

Personal Liability*

Coverage E Limit

Medical Payments*

Coverage F Limit

Water Backup / Sewer Backup*

Ordinance of Law Coverage*

Identity Theft Coverage*

Personal Injury*

Scheduled Personal Property*

Put "0" (zero) for items not required*

Section: (For Mobile / Manufactured Homes)

Dwelling Coverage*

Coverage A Limit

Detached Structure*

Coverage B Limit

Personal Property*

Coverage C Limit

Loss of Use / Loss of Rents*

Coverage D Limit

Personal Liability*

Coverage E Limit

Medical Payments*

Coverage F Limit

Water Backup / Sewer Backup*

Ordinance of Law Coverage*

Identity Theft Coverage*

Personal Injury*

Scheduled Personal Property*

Put "0" (zero) for items not required*

Section: (For Renters requiring an HO4 Policy)

Personal Property*

Coverage C Limit

Loss of Use / Loss of Rents*

Coverage D Limit

Personal Liability*

Coverage E Limit

Medical Payments*

Coverage F Limit

Water Backup / Sewer Backup*

Identity Theft Coverage*

Personal Injury*

Scheduled Personal Property*

Put "0" (zero) for items not required*

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Copy of Policy, Drivers License, ETC

Notes:

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