Homeowners Insurance Application
1STOP Insurance Agency - (800) 858-5855
Property Address:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different from property address):
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Personal Information
Please enter information below
Name
First Name
Last Name
Gender
*
Male
Female
Date Of Birth
*
-
Month
-
Day
Year
Date
Social Security # Optional
Optional, but helpful
Marital Status
*
Single
Married
Divorced
Engaged
Separated
Other
E-mail
*
example@example.com
Phone Number (Home or Mobile)
*
-
Area Code
Phone Number
Phone Number (Home or Mobile)
-
Area Code
Phone Number
Other applicants to be covered -
(Leave Blank if no other applicant is to be added)
Name
First Name
Last Name
Suffix
Relationship to Applicant:
Spouse
Child
Parent
Business
Other
Home Information
Please enter information below
When would you like policy to begin
*
-
Month
-
Day
Year
Date
Type Of Insurance Requested
*
Home
Manufactured Home
Mobile Home
Renters
Condo
Other
Are you currently insured
*
Yes
No
Current insurance company
When does current policy expire?
-
Month
-
Day
Year
Date
What Year Was Home Built?
Purchase Date (Approximate)
*
Take Photo of the home from front yard facing the home
Take Photo of the home from backyard facing home
How Much Would It Cost To Replace Your Home?
*
Square Footage
Number Of Stories
1
1.5
2
2.5
3
Other
Approximate Distance to Fire Department in miles
Distance To Fire Hydrant (Feet)
Please Select
1 - 500
510 - 600
601 - 1000
1001 - 2640 (half mile)
2641 - 5680 (mile)
1 - 3 miles
3 - 5 miles
5 - 10 miles
More Than 10 miles
Is this home your primary or secondary home?
*
Please Select
Primary
Secondary
Seasonal
Farm
Other
Occupancy Type
*
Please Select
Owner Occupied
Renter Occupied
Unoccupied
Under Construction
Other
Number of Acres
Less Than 1 Acre
1 - 5 Acres
5 - 10 Acres
More Than 10 Acres
Is Home Located Within City Limits
*
Yes
No
Other
How Many Families Live In The Home
*
Please Select
1 Family
2 Families
3 Families
4 Families
More
Number of Residents
*
Only list residents over the age of 18
Are you (or any other resident) a smoker
Yes
No
Home Details
Please enter the information below, if you are unsure of the answer, please leave blank of permitted.
What is the construction type of the home / dwelling (60% or more)
Please Select
Adobe
Aluminum vinyl
Barn plank
Brick
Brick on block
Brick on block custom
Brick veneer
Brick veneer custom
Cement fiber shingles
Clapboard
Concrete decorative
Exterior insulation
Fire resistant
Logs
Poured concrete
Siding aluminum
Siding hardboard
Siding plywood
Siding steel
Siding - T-111
Siding vinyl
Siding wood
Slump block
Solid brick
Solid brick custom
Solid brownstone
Solid stone
Solid stone custom
Stone on block
Stone on block custom
Stone veneer
Stone veneer custom
Stucco
Stucco of block
Stucco on frame
Victoria scalloped
Window wall
Wood shakes
What type of roof does the home / dwelling have
Please Select
Architectual shingle
Asbestos
Composition
Copper flat
Copper pitched
Corrugated steel flat
Corrugated steel pitch
Fiberglass
Foam
Gravel
Metal / flat
Metal / pitched
Mineral fiber shake
Other
Plastic flat
Plastic pitched
Rock
Rolled paper flat
Rolled paper pitched
Rubber flat
Slate
Solar
Thatch
Tar
Tar / gravel
Tile clay
Tile concrete
Tile Spanish
Tin flat
Tin pitched
Wood fiberglass
Wood shake
Wood shingle
Roof design
Please Select
Dormer
Flat
Gable
Gambrel
Hip
Other
Pyramid
Shed
Turret
Foundation type
Please Select
Basement finished
Basement part finished
Basement unfinished
Crawl space enclosed
Crawl space open
Daylight basement
Hillside foundation
Piers
Pilings / stilt slab
Berm
Year roof was updated
Number of full baths
*
Primary Heat Source
Electric
Gas
Oil
Other
Primary heat source
*
Do you have an alternate source of heat other than a fireplace (e.g. wood burning stove)?
Yes
No
Other
Year the heat renovated / replaced
Does home have a circuit breaker
*
Yes
No
Year electrical updated
Year plumbing updated
Do you conduct any type of business on this property? (e.g. daycare, beauty salon)?
*
Yes
No
First mortgage
Yes
No
Second mortgage
Yes
No
Do you own any dogs of the breeds (Rottweiler, German Shepard, Doberman, Pitbull, Chow, Wolf Hybrid or mix of these)?
*
Yes
No
Property Accessories
Does the home / dwelling have any of the following
Swimming pool
*
Yes
No
Trampoline
*
Yes
No
Smoke detector
*
Yes
No
Fire alarm type
*
Central (monitored by paid service)
Direct (monitored by you)
Local (alarm or siren only)
Fire extinguisher
*
Yes
No
Indoor fire spinkler
*
Yes
No
Burglar alarm
*
Yes
No
Type of burglar alarm
*
Central (monitored by paid service)
Direct (monitored by you)
Local (alarm or siren only)
Deadbolt
*
Yes
No
Gated community
*
Yes
No
Home Coverages
NOTE: Please choose the desired coverage. This is a key way to insure your home AND help to influence the rate or premium. Try to copy current coverage, your agent will assist you as well.
Medical payments
*
None
1000
2000
3000
4000
5000
Other
Personal liability Coverage
*
25,000
50,000
100,000
200,000
300,000 - (Popular Coverage)
500,000 - (Popular Coverage)
Other
Select your deductible
*
1/2% Coverage A
1% Coverage A
100
250
500
1000
2500 (Popular Deductible)
5000 (Popular Deductible)
7500
10,000
Select your wind / hurricane / hail / tornado deductible
*
1/2% Coverage A
1% Coverage A
100
250
500
1000
2500 (Popular Deductible
5000 (Popular Deductible
7500
10,000
Earthquake Coverage
Please Select
Yes
No
Water backup coverage
*
Please Select
Yes
No
Increased jewelry limit
Please Select
Yes
No
Identity theft protection
Please Select
Yes
No
Loss Info
Please list any losses / claims / inquiries over the past 5 years
Have you have any losses, claims or inquiries in the past 5 years? If so, please list them below.
*
Yes
No
Date
-
Month
-
Day
Year
Date
Loss #1
What type of event
Date
-
Month
-
Day
Year
Date
Loss #2
What type of event
Date
-
Month
-
Day
Year
Date
Loss #3
What type of event
Are you interested in an auto / home bundled discount?
*
Yes
No
I acknowledge this information is used to obtain an insurance credit score (NOT an impact on credit score or rating).
*
Yes
No
I acknowledge and accept the Disclaimer / Terms of Use and the Privacy and Security Statement of this website / app.
*
Yes
No
I also acknowledge my understanding that the accuracy of the quotes that are presented are dependent on the accuracy of the information that I provide.
*
Yes
No
Comment
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