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General Information
How did you learn about our agency?
What is your scheduled settlement date? (New Purchase Only)
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Month
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Day
Year
Date
We assume that you are moving in to the new property within 30 days after settlement. If not, please explain? For example, is there a rent back situation? If so, we need to know.
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What is your scheduled settlement date? (New Purchase Only)
Are you interested in a quote with a particular insurance company?
We represent Chubb, Travelers, Hanover, PURE, and Cincinnati
Are you interested in a quote with a particular insurance company?
Chubb
Travelers
The Hanover
Pure
Cincinnati
Not interested in a specific company
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Client Information
Are you single or married?
Marital Status
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Single
Married
Divorced
Widowed
Separated
Full Legal Name - Person 1
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First Name
Last Name
Birthday - Person 1
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Month
-
Day
Year
Date
Occupation / Employer - Person 1
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Email - Person 1
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example@example.com
Phone Number - Person 1
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Please enter a valid phone number
Format: (000) 000-0000.
Is there another person that should be named on this policy?
Yes
No
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Full Legal Name - Person 2 (If Applicable)
First Name
Last Name
Birthday - Person 2 (If Applicable)
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Month
-
Day
Year
Date
Occupation / Employer - Person 2 (If Applicable)
Phone Number - Person 2 (If Applicable)
Please enter a valid phone number.
Format: (000) 000-0000.
Email - Person 2 (If Applicable)
example@example.com
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Policy Information
Are there any other names on the policy or a trust that needs to be listed?
Address Of New Purchase
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Address Where You Live Now
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Will this be your primary home or a rental property that you are buying?
This property will be your
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Primary home
Rental property
Secondary-Not rented
Does this property have a (check all that apply)
Swimming pool
Hot tub
trampoline
Do you currently have home or condo or renters insurance? If so, what carrier are you currently insured with?
Do you currently have home or condo or renters insurance?
Yes
No
What is the name of your current insurance company?
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Additional Details
Have you had any homeowner's claims in the last 5 years? If so, please provide dates of loss and details.
Have you had any homeowner's claims in the last 5 years?
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Yes
No
If so, please provide dates of loss and details.
Does the new home have a swimming pool or hot tub?
Has your insurance been cancelled/declined/non-renewed in the last 3 years?
Do you conduct any type of business on the premises (e.g. daycare, kennel, bed and breakfast)?
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Is your entire home or any part of it available for rent, including short-term vacation rental or home sharing/swapping? If so, is the entire home rented? A Room or Floor in the home? Garage/Guest House? Is it rented daily/weekly/monthly? Or is there a 6 month or greater lease in place?
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Do you have a dog(s)?
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If you have a dog, have they ever bitten anyone?
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Do you or any household member own one or more of the following breeds or a mix of one of these breeds of dogs (Akita, Alaskan Malamute, American Bull Terrier, American Staffordshire Terrier, Mastiffs, Chow Chow, Doberman Pinscher, Pit Bull, Presa Canario, Rottweiler, Staffordshire Bull Terrier, Wolf Hybrid)?
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Will you have a centrally monitored burglar and/or fire alarm monitored by a third-party company like ADT on your new home? If so, please specify if it is burglar only or fire only or burglar and fire.
Will you have a centrally monitored burglar and/or fire alarm monitored by a third-party company like ADT on your new home?
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burglar only
fire only
burglar and fire
not sure
Are there sprinklers on the ceiling of the home for fire suppression purposes?
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Is there a working smoke detector in the new home?
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Does your home have
a back-up generator for the whole house
an automatic water leak detection system monitored by an outside company
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Property Details
What year was the home built?
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What is the square footage of the new home (excluding the basement)?
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What type of heat does the home have? Central Gas? Central Oil? Central Electric? Other? Specify below.
What year was the Heating (HVAC) system last replaced?
Do you have a wood/coal/pellet stove in the new home?
What is the construction type of the new home? All brick? Siding? 1/2 and 1/2? What type of siding (Vinyl/Aluminum)?
How many stories are in the home (excluding basement)?
Is there a basement in the home? If so, what % is finished vs. unfinished for the basement?
Is there a sump pump in the basement? If so, is there a backup power source in case the power goes out?
How many bedrooms are in the home?
How many full bathrooms in the house and how many half bathrooms in the house?
Is there a garage? If so, how many cars? Attached? Detached? Built In?
What type of roof is on the house? Shingle? Slate? Rubber? Tar?
What year was the roof last replaced? If this is a condo then please reply N/A, but all home insurance carriers require this information as of March 2025.
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Are there solar panels on the roof? If so, how many?
Does the house have Electric Circuit Breakers? We need to verify and confirm no knob and tube wiring.
Is there a deck on the house? If so, approximate square footage?
How many fireplaces does the home have?
How many sliding glass doors to the outside of the home?
How many exterior french doors to the outside of the home?
If this is a condo then how much personal property ("contents") would you like to insure? For example, please consider the total value for all of your clothes, furniture, electronics, etc. Basically everything that you are bringing in to the unit that needs to be insured by you.
There are limitations in the policy for higher valued items such as jewelry, silver, art, antiques, furs, musical instruments, etc. A lot of people will separately insure their engagement ring and wedding bands to make sure that they are properly insured. Do you need any additional coverage for any of these higher valued items? If so, what class do you need coverage for, and how much coverage do you need?
Earthquake is not a covered peril in the homeowners policy, but you can purchase the coverage by endorsement if you are interested. Please let us know if you would be interested in a quote for Earthquake Insurance.
Flood is not a covered peril in the homeowners policy, but you can purchase the coverage if you are interested. Please let us know if you would be interested in a quote for Flood Insurance.
Is there a mortgage on the home? If so, can you please let us know the name and contact info for your lender?
NOTE: Please let us know if you would also be interested in an auto quote since bundling both your home and auto policies at the same time can help reduce the premium. If so, you can email or upload us a copy of your current auto insurance declarations page. We would also need your Drivers License State and Number.
Feel free to update any info that you have that may be helpful like a bank appraisal, inspection details, copy of policy, etc.
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