Home Insurance Quote

Required Document for All New Business HO and DP Policies (Not designed for builder's risk or vacancy)
Basic Information
Applicant Name*

First NameLast Name
Agent
How did you hear about us?
Applicant DOB?*

MonthDayYear
Date
Is there a co-applicant?*

YesNo
Co-Applicant Name*

First NameLast Name
Co-Applicant DOB?*

MonthDayYear
Date
Will the property be owned by a corporation?*

YesNo
What is the corporation's name?*
Please provide corporation name as shown on property appraiser
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com or N/A if no email
Determining Policy Form

Questions Used to Determine Policy Needed
What will be the purpose of this property?*

HO - Residence of InsuredDP - Rental PropertyOther
What is the construction of the property?

Masonry - Block or ConcreteFrame - Wood or AluminumOther
How many months a year do you reside at this property?*

9-12 Months5-8 Months0-4 Months
Do you require at least an annual lease?*

YesNo
Do you allow any form of short term rental?*

YesNo
What is the home type?*

Single FamilyTownhouseModularMobile HomeCondoOther
How is Mobile Home Situated?*

Non-Owned Private PropertyOwned Private PropertyMobile Home ParkSenior Mobile Home Park
Are you responsible for the exterior of the property and the roof?*

YesNo
Make of the Home?*
Ex. Fleetwood or Palm Harbor if unsure notate.
Square Footage of Mobile Home*
Customer can also provide length and width
Serial Number of the Home?
Typically located in kitchen cabinet or master closet if unsure notate.
Age of the Mobile Home?*
Structures of the Mobile Home?*
Ex, Attached Sunroom 400 square foot worth 5,000 or unattached shed that is 350 square feet worth 3000. If no other structures are provided put N/A in the field.
Discount Questions!

The best part of the form!
Do you have a wind mitigation form?*

YesNo
Alarms in the home?*

YesNo
Specify Further?*
Please note monitored alarms can be ONLY burglary, ONLY fire, or BOTH. Local can simply be smoke detectors or un-monitored alarm.
If Home is new construction, who is the builder?
Only ask this question if home is currently under construction or was very recently finished being built.
Community Access Discount?

Single EntryGated with GuardsKeycode Entry Gated
Underwriting Questions

These are some of the most common underwriting related questions that arise that can affect eligibility
Is there any existing damage or debris on the property?*

YesNo
Has coverage on this property been cancelled, rejected, or non-renewed in the last three years?*

YesNo
Will the property be occupied within 30 days of effective date?*

YesNo
Do you own any animals?*

YesNo
What kind of animal?*
Include species and breed. (ex. a dog; chihuahua)
Pool on the property?*

YesNo
Pool Area Screened? OR Yard Entirely Fenced?*

YesNo
Are there currently any type of renovations or construction occurring on the property?*

YesNo
Was the home purchased through short-sale or foreclosure?*

YesNo
Does your home have any burglar bars installed?*

YesNo
Do the bars have quick release mechanisms?*

YesNo
Loss History
Has this property or any properties you've owned sustained in damage that resulted in a claim in the past 5 years?*

YesNo
Please detail all losses with locations, dates, amounts, type of damage, and status of claim.*
Ex, Water Damage 5/10/2015 $30,000 Paid Out Claim is Closed.
Update Questions

Questions used to determine age of major systems in home for discount and eligibility purposes.
Year Roof was Installed/updated?*
Roof Type*
Please Describe*
Year HVAC was installed/updated?*
Year plumbing was installed/updated?*
Are you aware of the presence of Polyethylene in your home?*

YesNo
Year electrical was installed/updated?*
To your knowledge is your electrical panel made by Federal Pacific or Sylvania?*

YesNo
To your knowledge does your home contain any aluminum, cloth, or knob and tube wiring?*

YesNo
Please retain this completed on the applicants file. If the applicant purchases a policy, this document is required to be sent for signature alongside their applicant and should be saved on the file after signature is obtained.
Customer Signature

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Basic Information

Determining Policy Form

Discount Questions!

Underwriting Questions

Loss History

Update Questions