Residential Property Insurance

PERSONAL LINES APPLICANT
Required Insured Information
Insured Name*

First NameLast Name
Named Insured Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Code Description and Name (if applicable)
What is the Value of the Home?*
Named Insured Physical Location Address **

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
What is a premium amount to target?*
Current Insurance Carrier:*
Expiration Date of Current Policy
Target Effective Date*

MonthDayYear
Date
Additional Insured Information
Number of Properties to Insure
Example 1 or 3
H03H04H05H06H08DP1DP3
PrimarySecondarySecondary/RentalShort Term RentalAnnual RentalBuilders RiskVacant
Lived in Property or RentOwnerRentAirbnb
(I) Individual(C) Corp
YesNo
SECURITY SYSTEMS (Mark with a X where appropriate - If known)
Mailing address (or current if buying a new property)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior insurance (Not appilcable if new owner)
Current Policy - Declarations Page

Cancelof
4 Point Inspection

Cancelof
Wind Mitigation Inspection

Cancelof
LENDER, FINANCE INFORMATION
Dwelling Limit*
Personal Property*
Liability
Medical Payments*
Other Structures*
Loss of Use*
AOP Deductible
Hurricane Deductible*
Property Information
SECURITY SYSTEMS (Mark with a X where appropriate - If known)
Year Built
Square Feet
Number of stories
Distance to Hydrant
Fire Burglary Protection
Monitored Burglar Alarm, Monitored Fire Alarm, Combo Alarm
Distance Fire Dpt
Other Water Source
Other Water Source
PartialCompleteNo Update
PartialCompleteNo Update
PartialCompleteNo Update
PartialCompleteNo Update
Additional Underwriting Information
PartialCompleteNo Update
PartialCompleteNo Update
YesNo
YesNo
Claims Information (last 5 years)*
Comments To Underwriter:
Mitigation Information
GableHipFlat
Asphalt ShingleArchitectural ShingleClay TileCement TileMetalBuild-up Tar & Gravel
ToenailsClipsStraps
YesNo
Distance to Coast (miles to coastline/waterways):*
Florida Building Code*
I certify that the information provided in this form is complete and accurate to the best of my knowledge, information and belief.
Date

MonthDayYear
Date
The parties understand and agree that to the extent that they sign electronically, that their signature is the legally binding equivalent to their handwritten signature. You agree that you will not at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature was or is not legally binding.
This affidavit template is designed to authorize your company or an individual to collect and use information to process quotes with insurance carriers.

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PERSONAL LINES APPLICANT

Required Insured Information

Property Information

Additional Underwriting Information

Mitigation Information

I certify that the information provided in this form is complete and accurate to the best of my knowledge, information and belief.