Time-Sensitive Property Coverage Intake

Time-Sensitive Property Coverage Intake

For clients requiring expedited property coverage
Coverage Context & Timing
Submission Date

MonthDayYear
Date
How were you introduced to our firm?
Referring Client or Professional
Name & firm
What best describes the timing of this request?

Property currently in escrowNotice of non-renewalReplacement of expiring coverageRecent lapse in coverage requiring replacementOther time-sensitive circumstance
Please share any additional timing or coverage context
Please share the reason coverage was non renewed.

Carrier withdrawal from stateCarrier underwriting appetite changeCoverage suspended pending underwriting requirementsClaims history impacting eligibilityOther
Please share any underwriting-related details that may be relevant
Most recent or current insurance carrier
Name
Target effective date for coverage

MonthDayYear
Date
Insured & Ownership Information
How will the property be titled?

Individual OwnershipTrustLLCCorporationAssociationOther Entity
Primary Insured – Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Occupation / Business Activity*
Marital Status*

MarriedNot Married
Spouse / Partner – Full Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Occupation / Business Activity
Name of Trust or LLC
Name
Name of Corporation or Entity

Entity Legal NameDBA (if applicable)
Is there another individual or entity that should be included on the policy?

YesNo
Additional Insured – Full Legal Name
Property Details
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Property Type*
Intended Occupancy within 60 days of effective date. (Select all that apply)*

Primary Home / Owner OccupiedSecondary Owner Occupied (no rental activity)Secondary / Seasonal (rental activity)Tenant Occupied (12 month lease)Short Term Rental (Less than 12 month lease)VacantUnder Construction
Building Usage*

OfficeRetailMedicalWarehouse/WholesaleManufacturingAutomobile ServicesRestaurantCoffee/Tea/JuiceHabitational UnitsOther
Number of Units*
How long have you owned or occupied your current residence?
Prior Primary Residence Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Existing Coverage Snapshot
If applicable, which carrier currently insures your primary residence, automobiles, and umbrella liability?
Do you own any additional residential or investment properties?
Personal Property & Collections
Certain personal property categories may require separate consideration. Do you have any of the following items valued over $1,000 each? (Select all that apply)

JewelryFine ArtFirearmsFursImported RugsSilverwareAntiquesNone of the above
If applicable, please list the items and approximate values
Protective Features & Exposures
Does the property currently have, or will it have, any of the following protective features?

Swimming Pool/JacuzziTrampolineSolar PanelsProfessionally Monitored Burglar & Fire Alarm SystemAutomatic Gas Shut Off ValveAutomatic Water Shut Off Valve and whole house leak detection monitoring
Does the property have a fire sprinkler system?
Do you have a recent fire sprinkler main drain test certificate?
Do you own or plan to own e-bikes or golf carts kept at the property?
Will you employ any residential or domestic staff directly (not through a third-party service)?

YesNo
Number of directly employed residential staff
Number
Will the property be used for short-term rentals (e.g., Airbnb, VRBO)?

YesNo
Will any in-home daycare or childcare services operate at this property?

YesNo
How many children does current licensing allow or is anticipated to allow?
Number
Are there any dogs residing at the property?

YesNo
If yes, do any of the following breeds apply?
Has any dog on the property ever bitten a person or another animal?

YesNo
Building & Systems
Year originally built
Approximate total square footage
Number of living stories
Roof Type
Year roof was last fully replaced (if known)
Year
Garage Type
Foundation type
Are there detached structures on the property?

NoneADUGuest/Pool HouseStudioBack HouseSwimming PoolSignificant Hardscaping: patios, walkways, etc.Outdoor Kitchen or hardscape built ins.Other
Describe OTHER:
Approximate detached structure square footage
Does the HOA master policy provide coverage for any of the following?

Common LiabilityThe Building ShellInterior build out of the units to their original specsInterior build out including all upgradesUnsure
Does the building contain any of the following recalled electrical panel types?

Federal Pacific Electric (FPE) Stab-Lok panelsZinsco / GTE Sylvania-Zinsco PanelsChallenger panels by Challenger Electric Equipment Corp or Eaton/Cutler-HammerPushmaticNone of theseUnsure
Year electrical system was last fully replaced (if known)
Type of electrical service / main panel
Primary wiring type

CopperAluminumUnsure
Primary plumbing type

PVCCopperGlavanizedOtherUnsure
Other Plumbing Details
Year plumbing system was last fully replaced (if known)
Primary heating system type
Is the heating system thermostat-controlled?

YesNo
Year heating and/or air conditioning system was last replaced (if known
Year each was updated
Are there security bars on any windows?

YesNo
If yes, do all bars have interior release mechanisms?

Yes, all have release latchesNo, only the bars on the bedrooms have release latchesNo, none have release latchesUnsure
Renovation & Construction
If construction or renovation will extend beyond 60 days from the coverage effective date, please select the scope of work that best applies.

Complete demolition and new ground up construction.Remodel: Taken down to the studs and built back up (like new construction).Remodel: Addition of square footage and/or stories.Remodel: Interior layout re design, including movement of load bearing walls.Remodel: Interior/Exterior cosmetic only (re roof, floors, built ins, paint, etc.)
Additional square footage planned
What will be built with the addition of square footage?

Additional Story(ies)Additional bedroom(s)/bathroom(s)Additional KitchenAttached ADUDetached ADUOther Separate Structures
Additional Number of Stories:
Additional Bedrooms/Bathrooms:
Describe the other separate structures you plan to build?
Estimated total construction or renovation budget*
$
Will the project include either of the following:

Foundation workEarthquake RetrofittingNeither
Rental, Management & Use
Annual Anticipated Rental Income?*
$
Will a property management company or property manager be used?

YesNo
Property Manager / Management Company's Name
Is there an On Site Property Manager?

YesNo
Financing & Documents
Are HOA CC&Rs available?(If yes, please forward separately)

YesNo
Is there an active mortgage on the property?

YesNo
Approximate remaining mortgage balance
$
Final Details
Additional notes or context
Mailing address (if different from property address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary contact name
Preferred phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Preferred email address*
example@example.com
This intake was completed by*

First NameLast Name
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Time-Sensitive Property Coverage Intake

Coverage Context & Timing

Insured & Ownership Information

Property Details

Existing Coverage Snapshot

Personal Property & Collections

Protective Features & Exposures

Building & Systems

Renovation & Construction

Rental, Management & Use

Financing & Documents

Final Details