Name:
*
Phone:
*
Email:
*
Date of Birth:
Marital Status:
Please Select
Single
Married
Property Address:
City:
State:
Zip Code:
Is Mailing Address Different?
Yes
No
Mailing Address:
City:
State:
Zip Code:
Owner Occupancy:
Please Select
Owner Occupied
2nd Home
Rental
How Many Stories?
Style of Home:
Please Select
Ranch
Rambler
Other
Describe Style of Home:
What Year Was the Home Built?
How Many Square Feet?
How Much Do You Want To Insure It For?
Exterior Wall Construction:
Please Select
Stucco Over Frame
Stucco Over Masonry
Masonry
Wood Clapboard
Other
Describe Exterior Wall Construction:
Roof Material:
Please Select
Spanish Tile
Asphalt Shingle
Wood Shake
Concrete Tile
Other
Describe Roof Material:
Foundation:
Please Select
Concrete Slab
Basement
Crawl Space
Other
Describe Foundation:
Out of 100% total, what percentage is each of these
What Percentage Is Tile?
What Percentage Is Wall-To-Wall Carpeting?
What Percentage Is Linoleum?
What Percentage Is Hardwood?
What Percentage Is Concrete?
Percentage Of Any Other Material Not Listed Above?
Does The Home Have A Pool:
Yes
No
Is There A Fence Around The Pool or Property
Yes
No
Is There A Self Locking Gate:
Yes
No
Is There A Diving Board or Slide:
Yes
No
Distance From An Active Volcano?
Distance From The Ocean?
Is Your Home In A Retirement Community:
Yes
No
Name Of Retirement Community:
Are You In A Gated Community:
Yes
No
Is Your Home Located On:
Yes
No
Which Fire Department Is Your Responding Fire Department?
How Many Miles To The Nearest Fire Station?
How Many Feet From Your Home To The Nearest Fire Hydrant?
Has Your Home Had Any Upgrades:
Yes
No
What Was Upgraded:
Roof
Electrical
Plumbing
Heat / AC
When Where The Upgrades Done?
Does Your Home Have A Working Alarm System?
Yes
No
Who Is Your Alarm Company?
Does Your Home Have A Working Fire Alarm?
Yes
No
Who Is Your Fire Alarm Company?
Does Your Home Have An Indoor Sprinkler System:
Yes
No
Is Your Home In Good Condition and NOT In Need Of Repairs?
Yes
No
What Needs Fixing?
Does Your Home Have A Skateboard Ramp:
Yes
No
Does Your Home Have A Trampoline:
Yes
No
Do You Have A Fireplace In Your Home:
Yes
No
Type of Fireplace:
Franklin Free-Standing Metal Stove
Built-In Masonry
How Many Fireplaces in your Home?
Do You Currently Have Homeowners Insurance:
Yes
No
Who Is Your Homeowner Insurance Provider?
Do You Have A Mortgage On Your Home?
Yes
No
Do You Have Any Sort Of Expensive Personal Property That May Need Additional Coverage?
Yes
No
What Expensive Personal Property Do You Need Coverage For?
Do You Have Auto Insurance?
Yes
No
Who Is Your Homeowner Insurance Provider?
Do You Have Any Insurance Policies with Other Providers?
Yes
No
Which Insurance Provider Do You Have Current Policies With?
Do You Have Any Pets?
Yes
No
Type of Pets?
Any History of Biting?
Yes
No
Do You Have An Attached Garage
Yes
No
How Many Cars will your Attached Garage Hold?
Do You Have Deck, Porch, or Breezeway?
Yes
No
How Big is Deck, Porch, or Breezeway?
Type of Structure:
Enclosed
Open
Screened
How Many Full Baths Are There?
How Many Half Bath Are There?
How Big is Deck, Porch, or Breezeway?
Bath Style:
Basic – Formica Countertop
Custom – Granite Countertops
Designer – Higher Quality Countertops
Kitchen Style:
Basic – Formica Countertop
Custom – Granite Countertops
Designer – Higher Quality Countertops
Other Features
Is There Any Skylights?
Yes
No
How Many Skylights?
How Many Sliding Glass Doors?
Is There A Jacuzzi?
Yes
No
Is The Jacuzzi Indoor or Outdoor?
Indoor
Outdoor
How Many French Doors?
Any Wet Bars?
Yes
No
Supplementary Heat?
Yes
No
Does The Home Use Gas?
Yes
No
What Is Gas Used For?
Please Select
Water Heater
Stove
Heat
Other
Describe Other Gas Use
Any Solar?
Yes
No
What Is Solar Used For?
Please Select
Water Heater
Stove
Heat
Other
Describe Other Solar Use:
Any Handicapped Accessible Equipment?
Yes
No
What Type of Accessible Equipment?
Please Select
Hoyer Lift
Staircase Rail Lift
Other
Other Accessible Equipment:
Any Golf Cart?
Yes
No
Any ATVs?
Yes
No
Any Snowmobiles?
Yes
No
Any Scooters?
Yes
No
Any Other Features?
Additional Information We Should Be Aware Of?
Approximate Value Desired For Home?
If Rental, Is there a Lease Agreement?
Yes
No
If So How Long?
Personal Property Value?
Standard Deductible:
Please Select
$500
$1000
Other
Enter Deductible Amount:
Hurricane Deductible
Please Select
2%
5%
10%
$1000
How Far From The Ocean Are You?
Are You In A Flood Zone?
Yes
No
Any Additional Upgrades To Home?
Yes
No
Please Describe Additional Upgrades To Home
Submit
Should be Empty: