Home, Landlord and Flood Policy
TWFG Landeche Insurance 504-228-7184
Insured Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
E-mail
*
Co -Applicant
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Applicant's Marital Status
*
Please Select
Single
Married
Domestic Partner
Divorced/Legally Separated
Widowed
Other
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you lived at a different primary address in the last 2 years?
*
Yes
No
Previous Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
What type of Policy
*
Please Select
Homeowners
Homeowners & Flood
Landlord
Landlord & Flood
Flood Only
A flood quote might require an elevation certificate. Please upload
Flood elevation Certificate. Please attach if available.
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Do you have currently have homeowners Insurance?
*
Yes
No
Is this a new Purchase?
*
Yes
No
What is the reason you did not have insurance?
*
What is the date you last had home insurance?
*
-
Month
-
Day
Year
Date
What is your current dwelling amount?
*
Coverage A
Current Insurance Company
*
Annual Premium
Date you would like coverage effective
*
-
Month
-
Day
Year
Date
Type of Home
*
Please Select
Single Family
Duplex
Triplex
Fourplex
Townhouse
Number claims in past 6 years
*
Please Select
0
1
2
3
4
5 or more
Please give date of claim, amount of claim and cause of claim.
*
Does the home have any pre-existing damage?
*
Yes
No
Basic Information
Year Built
*
Square Feet
*
Number of Stories
*
Number of Baths?
*
1
2
3
4
5
6
7
8
9
10
Number of Half Baths?
0
1
2
3
4
5
6
7
8
9
10
Home Color
*
This makes it easy to find on google maps.
Plumbing Update year?
*
If never put year built
Primary Heating Type?
Please Select
Gas
Electric
Other
Other ?
*
Primary Heating Type
Heating year ?
*
If never put year built
Water Heater year?
*
Installed or updated
Wiring update year?
*
If never put year built
Roof Replaced year?
*
If never put year built
Occupied by
*
Please Select
Owner
Tenant
Vacant
Secondary
Renter
Relative
Back
Next
Exterior Information
Construction
*
Please Select
Masonry Veneer (Brick)
Stucco
Hardboard
Asbestos
Aluminum Siding
Vinyl Siding
Wood Siding
Cement Fiber
Foundation
*
Please Select
Slab
Raised
Stilts
Roof Material
*
Please Select
Architectural
Composition
Tile
Wood
Metal
Tar & Gravel
Roll Roof
Aluminum
Concreate 65 yr
Do you have a Fortified Roof?
Please Select
Yes
No
Type of Roof
*
Flat Roof
Gable Roof
Hip Roof
Back
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Other Information
Do you have Hurricane Shutters
*
Yes
No
Do you have a fire alarm- central reporting
*
Yes
No
Do you have a burglar alarm - central reporting
*
Yes
No
Do you have a fire place?
*
Yes
No
What Type?
*
Wood Burning
Gas
Electric
Electrical
*
Please Select
Circuit Breaker
Fuses
Central Air and Heat?
*
Please Select
Yes
No
Do you have a Home Generator Permanently Connected?
Please Select
Yes
No
Garage or Carport
*
Please Select
Yes
No
Attached
*
Please Select
Yes
No
How many Cars?
*
1 Car
2 Cars
3 Cars
Do you have a Patio Cover?
*
Please Select
Yes
No
Attached or Detached
Do you have a swimming pool?
*
Please Select
Yes
No
Type of pool?
*
Please Select
In Ground
Above Ground
Indore Pool
Do you have a fenced in yard?
*
Yes
No
Do you have a slide or diving board?
*
No
Slide
diving Board
both
Trampolines
*
Please Select
Yes
No
Do you have any dogs?
*
Yes
No
How many?
*
What breed?
*
Do you need another type of insurance quote?
*
Yes
No
Please Specify
*
How did you hear about us?
*
Google, Facebook, Bing and etc.
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