Homeowners
Name of Policy Holder:
First Name
Last Name
Mailing Address:
Street
Suite / Apt
City
State
Zip Code
Primary Residence Address:
Street
Suite / Apt
City
State
Zip Code
Owners Date of Birth
Email Address
e.g. example@example.com
How Long have you lived at Primary Residence address:
Cellphone Number
Enter a valid number.
Are you currently insured?
Yes
No
(If yes, who is your insurer?)
What date is your policy renewing?
-
Mes
-
Día
Año
Date
What is your current insurance premium?
Have you had insurance consecutively without a lapse for the past 24 months?
Yes
No
Have you had a non-pay cancel in the last 24 months with a lapse greater than 30 days?
Yes
No
Have you had home and or rental policy canceled by an insurance company (except for non-payment of premium) within the past 5 years?
Yes
No
What is the year the home was built?
Year Roof Updated
Year Electrical Updated
Year Plumbing Updated
Year HVAC updated
What is the square footage of the home?
How many stories does the home have?
Is there a basement? If so is it finished?
What is the construction type? (Frame, brick, metal, or other _________)
What type of roof does the home have? (Asphalt Shingles, metal or other )
What is the home's heating system? (Gas, Electric, or other)
Are there any updates or renovations in past 20 yrs? (Plumbing, electrical, roofing, HVAC)
What is the estimated replacement cost of the home?
What personal property coverage do you want? (Contents inside the home)
Are there any safety features in the home? (Smoke detectors, security system, etc.)
Have you had any previous claims on this property in past 36 months?
What is your deductible preference? (The amount you’ll pay out of pocket before coverage kicks in)
Do you have any other insurance policies with the company? (Auto, life, RV, ATVs etc.)
Do you operate a business from home?
Is the home located in a flood zone or high-risk area?
Person Completing Application
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: