Homeowners/Dwelling/Landlord Insurance Quote

Homeowners/Dwelling/Landlord Insurance Quote
Name

First NameLast Name
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Marital Status
Occupation Industry
Occupation Title
Is there a co-owner (additional name on deed. ex. Spouse)
Spouse/Co-Owner

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to you
Occupation Industry
Occupation Title
Is Property Address also Mailing Address?
Property Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Safety Features (select all that apply & give details below)

Other
Is the property currently insured?
Reason for no current insurance
Current Insurance Carrier (or prior if policy is lapsed/cancelled/expired)
Expiration/Cancellation Date of Current/Prior Insurance

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Years with Current/Prior Insurance Carrier
Miles to nearest Fire Station
Feet to nearest Fire Hydrant
Year Home was Built
Electric circuit breaker present?
Square Footage of Home
Purchase Date/Closing Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Type of Dwelling
If "other", please explain in "additional info" below
List Manufactured/Modular Home Make, Model, Serial Number, Length & Width
Dwelling use
List all types of tenant screenings used
Enter "None" if no tenant screenings are used
Are tenants required to carry personal liability with you listed as additional interest?
Tenant Personal Liability requirements
How many people live at address?
Roof Type
Please Describe "other" Roof Type
Ex. Wood Shake
Age of roof in years
Enter "0" if less than 1 year
Foundation type
Exterior of Home
Garage type
Detached Structures (please list all)
Please give dimensions of structures in feet ex. 20x30
Number of full bathrooms
Number of half bathrooms
Primary heat source
Heating fuel type
Dwelling Coverage
Amount to rebuild home in total loss
Personal Property Coverage Limits
Please indicate higher percentage requested in "additional info" below
Deductible
Please indicate higher deductible requested in "additional info" below
Personal Liability Coverage Limits
Please indicate higher liability limits requested in "additional info" below
Medical payments to others
Please indicate higher medical payments limits requested in "additional info" below
Payment plan requested
Claims in last 5 years
If no claims, enter "0"
Give details of claims including date, type of loss, and amount paid by insurance.
Have any of the following been updated since home was built (check all that apply)

Other
Give details of updates including the year update(s) were made.
(ex. Natural gas insert 2020)
Pool?
Pool area surrounded by 4ft+ high fence? Or above ground pool with lockable ladder?
Trampoline?
Anyone in the household smoke?
Is there any business activity, farming, or daycare on the premises
Please explain business, farming, or daycare below including if there is customer traffic on premises and if it is source of income.
Daycare operations will require additional questions, but please include all info you consider relevant to operations.
Any aggressive breed animals, animals with a bite history, exotic animals, or farm animals?
List breed/type of animals and explain
Additional information (please include info for any questions above that require further explanation, otherwise it may affect if carriers offer you a quote or discounts)
Type "N/A" if no additional information applies
Most insurance companies use information provided by the customer and other sources, such as claims and credit histories, to calculate an accurate price for insurance. By clicking "Submit" to this form, you authorize Shoals Insurance Group to pull any necessary reports through the insurance companies in order to receive quotes on your behalf.
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