Homeowners Insurance Form

Homeowners Insurance Form
Your Name*

First NameLast Name
Your Date of birth*

MonthDayYear
DOB
Spouse Name (if single - leave blank)

First NameLast Name
Spouse Date of birth

MonthDayYear
DOB
Please enter the legal name under which the property is registered, such as LLC, Corp, or Trust. (if applicable).
What’s your Phone Number?*
Please enter a valid phone number.Format: (000) 000-0000.
What’s your email address?*
example@example.com
What’s the home address to be insured?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Your mailing address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I’m closing on a new homeI’m thinking of switching
When is the approximate closing date?*

MonthDayYear
Date
Year purchased*

MonthDayYear
Date
What is the name of the current insurance carrier?
What’s the annual premium?
Upload a copy of your existing policy so we may review and compare

Cancelof
Primary – Insured lives thereSecondary HomeSeasonal – Occupied 2–3 months per yearRented to others (Full lease tenant)Rented to others – Seasonal, (like Airbnb etc)
Detached HomeSemi-attachedTownhouseCondoCo-opMulti-unit
Single familyDuplex2 Units3 Units4 Units4+ Units
Name insured & FamilyRented out (DP3)
What's the annual rent amount collected from the tenants?*
AnnualShort-term
FrameBrickFire ResistiveJM
CrawlspaceBasementSlab
What is the year built?*
Number of stories:*
Square footage of the home:*
YesNo
FinishedPartially finishedUnfinished
Architectural ShingleAsphalt-FiberglassClay or ConcreteSlateTileMetalWood
Number of Full bathrooms:*
Number of half bathrooms:*
YesNo
YesNo
GasOilOther
Burglar alarmSecurity CamerasSprinkler SystemFire alarm - LocalFire alarm - Central StationNon of them
YesNo
YesNo
YesNo
What year was the roof last replaced?*
(Most carriers require it to be updated within the last 10-15 years.)
What year were the electric, heating, and plumbing systems last updated?*
(Most carriers require it to be updated within the last 20 years.)
CompletePartial
What was the purchase price paid for the house?*
What coverage amount are you requesting to be insured for?*
Please note that the insurance coverage amount is determined by each carrier based on their assessment of the actual replacement cost to rebuild the house in the event of a loss.
Flood InsuranceValuable Items (jewelry, artwork, etc.)Commercial InsuranceWorkers Comp InsuranceNone
Please list any valuable items (e.g., jewelry, artwork, etc.) you would like insured:*
Please upload an appraisal of the valuable items.

Cancelof
YesNo
Please provide details of any claims, including what happened, the date, and the amount of the loss.*
Anything else you would want the agent to know regarding the home?
Please select the broker you are working with on this submission.*
Should be Empty: