Landlord/Dwelling Fire Quote Request
(Available in Colorado, Wyoming, Kansas, and Texas)
Primary Applicant Information
Legal Name
*
First Name
Last Name
Property Address (to be insured by landlord/dwelling fire policy)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary residence address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary residence status
*
I own my primary residence
I am currently renting my primary residence
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Single
Married
Divorced
Domestic Partner
Widowed
Driver's License Number
*
Driver's License State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Industry and Occupation
*
Highest Education Obtained
*
No Highschool Diploma
High School Diploma
Some College - No Degree
Vocational/Technical Degree
Associates Degree
Bachelors Degree
Masters
PhD
Medical Degree
Law Degree
Have you been at your current primary residence less than 3 years?
*
Yes
No
Please provide previous primary residence address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Secondary Applicant Information (Spouse or Domestic Partner)
Legal Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Drivers License Number
*
Driver's License State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Highest Education Obtained
*
No Highschool Diploma
High School Diploma
Some College - No Degree
Vocational/Technical Degree
Associates Degree
Bachelors Degree
Masters
PhD
Medical Degree
Law Degree
Industry and Occupation
*
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Existing Policy Information
Starting date for new landlord/dwelling fire policy?
*
-
Month
-
Day
Year
Date
Name of insurance carrier providing current landlord/dwelling fire policy. If you do not currently have a policy, please provide the name of the insurance company covering your primary residence.
*
Years with current insurance carrier
*
Years of continuous landlord/home coverage without lapse in coverage
*
Has any prior dwelling policy been cancelled, declined, or non-renewed in the last 5 years?
*
Yes
No
If available, please upload the declaration pages of your current policy...
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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Dwelling Information - General
Year Built (YYYY)
*
Purchase Date (MM-YYYY)
*
Home Usage
*
Please Select
-Primary Residence with occasional short term rentals
-Primary Residence with section of home currently rented
-Secondary Residence
-Seasonal Residence
-Rental
Is the residence vacant?
*
Yes
No
Number of current occupants (including children)?
*
Please Select
1
2
3
4
5
6
7
8
Is there a business on the premises?
*
Yes
No
Do you have an HOA?
*
Yes
No
Are there any animals on the premises?
*
Yes
No
How many dogs on premises?
*
What breed of dogs?
*
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Dwelling Information - Amenities & Features
Which safety features are on the premises? Check all that apply.
*
Smoke Detectors
Dead Bolts on Doors
Fire Extinguisher
Indoor Sprinkler System
Alarm System (with 3rd party monitoring service)
Smart Home
None
Which option(s) best describes your foundation? Check all that apply.
*
Full Unfinished Basement
Full Finished Basement
Half/Partial Unfinished Basement
Half/Partial Finished Basement
Crawlspace
Slab
Walkout Basement
Do you have solar panels on roof?
*
Yes
No
Primary Heating Type
*
Please Select
Electric Baseboard
Gas - Forced Air
Gas - Hot Water
Oil - Forced Air
Oil - Hot Water
Radiant/Floor Heat
Other
Number of Wood Burning Stoves
*
Please Select
0
1
2
3
Are there any of the following amenities on the premises? Check all that apply
*
Trampoline
Inground Pool
Above Ground Pool
Inground Hot Tub
Above Ground Hot Tub
Diving Board
Pool Slide
Wet Bar
Central Vacuum
Home Theater
None
What is the pool depth under diving board (feet)?
*
Is there a safety net on the trampoline?
*
Yes
No
Do you have any patios, porches, or decks attached to the home? Select best option
*
None
Yes, open patio/porch/deck
Yes, enclosed patio/porch/deck
Yes, covered patio/porch/deck
Total square feet of patios/porches/or decks (approximate)?
*
List any detached structures on your property (shed, garage, pergola, playground, etc.)
Full Baths (count)
*
3/4 Baths (count)
*
1/2 Baths (count)
*
What type of flooring in home. Check all that apply.
*
Carpet
Hardwood
Vinyl
Ceramic Tile
Laminate
Other
What percentage of your flooring is carpet (approx.)
*
What percentage of your flooring is hardwood (approx.)
*
What percentage of your flooring is vinyl (approx.)
*
What percentage of your flooring is ceramic tile (approx.)
*
What percentage of your flooring is laminate (approx.)
*
What percentage of your flooring is other (approx.)
*
Cooling System
*
None
A/C
Swamp Cooler
Does your A/C system use the same ducts as your heating system?
*
Yes
No
Fireplaces (count)
*
Type of Fireplace. Check all that apply.
*
Gas
Wood
Chimneys (count)
*
Other special features/comments?
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Dwelling Information - Updates
Have any plumbing updates been made to the house since it was built?
*
Water heater replacement
New pipes installed
None
Year of most recent plumbing update?
*
Plumbing Pipes Material
*
Please Select
Copper
PVC
Pex Pipe
Unknown
Year heater/furnace was last installed or replaced?
*
When was furnace last serviced?
*
Have any electric and wiring updates been made to the house since it was built?
*
New boxes
New wiring
New Outlets
None
Year of most recent electric and wiring updates?
*
Does your house have circuit breakers?
*
Yes
No
Does your house have fuses?
*
Yes
No
Any knob and tube wiring?
*
Yes
No
Unknown
Number of Amps
*
Please Select
Under 100
100
150
200+
Unknown
Age of roof?
*
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Insurance Coverages (Optional)
Do you need flood insurance?
Yes
No
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You're all set! Click on the "Submit Quote Request" button to complete.
Submit Quote Request
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