Homeowners Insurance Intake Form

Homeowners Insurance Intake Form

202 Village Circle, Suite 1, Slidell, LA 70458
Date*

MonthDayYear
Date
Referred By*
Name*

First NameLast Name
Date of birth*

MonthDayYear
DOB
Social Security #*
Drivers License State and Number
Marital Status*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Spouse/Domestic Partner/Co-Insured

First NameLast Name
Date of birth

MonthDayYear
DOB
Social Security #
Drivers License State and Number
Marital Status
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What’s your home address?*

Street Address

Street Address Line 2

City, State and ZipState / Province

Postal / Zip Code
Address of Property to Be Insured Same as Above?

Yes
Address of Property to be Insured

Street Address

Street Address Line 2

City, State and Zip

Zip Code
Do you rent or own it?*

RentOwn
Date Purchased or Date of Act of Sale*

MonthDayYear
Date
Who lives in the property?*
What type of property is it?*

Single FamilyDuplexTriplex4 PlexTownhouseCondoMobile HomeManufactured HomeOther
How is the home used?*
When was your house built?*
Number of stories*
What is the LIVING AREA square footage of your home?*
Square Footage
Type of construction*
Exterior Wall Type*
Foundation*
# of Bedrooms*
# of Full Baths*
# of Half Baths*
Carport
Garage*
Garage # of Cars
Any detached structures?
Details about detached buildings/structures
Any screened enclosures?
Year Roof was Replaced*
Roof Covering*
Roof Geometry*

HipGableOther

Year of Most Recent Update*

Rows	Year
Plumbing
Electrical
HVAC
# of HVAC Units
Hot Water Heater

Does the home contain any Galvanized Plumbing?*

YesNoUnknown
Does the home contain circuit breakers?*

YesNo
Did your home undergo any substantial renovations? If so, when?
*Leave blank if no renovations or unknown
Please describe the type of work that was done
Details about renovations
Is there any existing damage to the home?
If yes, please describe.
Type of Heating/Cooling*

Central HVACWindow UnitsSplit UnitsOther
If window or split units, how many?
How do you heat your home?*

GasElectricOther
Do you have a Fireplace?*

NoWood BurningGasHow many fireplaces do you have?
How many hot water heaters do you have?*
Is/are the hot water heater(s) tankless?*

YesNoOther
Where is/are hot water heaters located in the home?*

AtticGarage1st Story2nd StoryOutsideLaundry RoomOther
Do you have any pets/exotic animals? If yes, please specify quantity, breed, age, bite/aggressive history?*
Do you have a pool?*

NoIngroundAbove GroundRemovable Ladder (for above ground pools)?Fenced yard?Diving Board?Slide?Other
Do you have a trampoline?*

YesNo
Does the home have any of the following?

Fire ExtinguisherSmoke DetectorsDeadboltsGated or Secured Community
Do you have any of the following?

Fire alarmMonitoredBurglar alarmMonitored
What is the name of the monitoring company?
Has any coverage been declined, canceled, or non-renewed in the last 3 years? If yes, please explain.*

NoYesExplain
Has the applicant had a Bankruptcy, Foreclosure, Repossession or Felony in the past 10 years?*

NoYesExplain
Is there any business use for the home? If yes, please explain.*

NoYesExplain
Did you file any home or property claim within the past 5 years?*

NoneOnly oneMore than one
Date of Claim Reason for Claim Claim Closed? Describe the Damage
Date of Claim Reason for Claim Claim Closed? Describe the Damage
Have you had a lapse in coverage?*

No this is a New PurchaseNo lapse. I have a current property insurance policy.Yes - Last Date of Coverage
Current Carrier Policy # Expiration Date Limit of Liability
Flood Carrier Policy # Expiration Date Cov A Amt
Is there a mortgage on the property?*

Yes and insurance is paid by LENDERYes but the INSURED pays the insurance and does NOT have an escrowNo Mortgage - Send the bill to the INSURED
Mortgagee Clause
Loan #
Do you want to upload your current policy information or enter it manually?

Upload files, pics, etc...Enter information manually
Upload a copy of your existing homeowners and flood declarations pages. Also include alarm monitoring invoice/certificate.

Please upload a copy of the alarm monitoring certificate if you have a monitored alarm.
Cancelof
Do you have any jewelry, guns, antiques, etc. that also need to be insured?*

YesNoDescribe
Do you have a personal umbrella policy?*

YesNoNo but I'd like to get a quote.
Are you interested in learning about of Life & Disability products to protect your most valuable assets?*

YesNo
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