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Start here for a great Home Insurance experience!
How did you hear about us?
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I am a current client
Google
Facebook
Other Social Media
A Customer Referred Me
Saw Your Sign
Met An Agent At An Event
My Mortgage Lender Referred Me
My Realtor Referred Me
Other
Person who referred you?
Which agent are you working with?
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Adrienne Boyd
AmyBeth Full
Andy White
Brad Davis
Christina van Eeden
Unknown
How is property deeded?
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Personal Name(s)
LLC
Trust/Estate
Other
Name of LLC or Trust/Estate?
Name
*
First Name
Last Name
My preferred name (nickname) is:
My Gender?
Please Select
Male
Female
Other
Date of Birth
*
/
Month
/
Day
Year
Required
Social Security Number
Optional - (but use dashes)
Occupation (if retired include previous occupation)?
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Email
*
example@example.com
Phone Number
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Please enter a valid phone number.
Do we have permission to communicate via text with you at this number?
*
Yes (recommended)
No
Marital Status
*
Please Select
Married
Single
Divorced
Widowed
Significant Other
Spouse's Name
*
First Name
Last Name
My spouse's preferred name (nickname) is:
Spouse's Gender?
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Male
Female
Other
Spouse's Date of Birth
*
/
Month
/
Day
Year
Required
Spouse's Occupation (if retired include previous occupation)?
*
Location Address
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Street Address
Street Address Line 2
City
State
Zip Code
Is this in a neighborhood or subdivision?
*
Please Select
Yes
No
Name of the neighborhood or subdivision?
*
Is the neighborhood or subdivision gated?
*
Please Select
No
Yes - with card or barcode access
Yes - with 24 hour security
Yes - other
Is Mailing Address the same?
*
Please Select
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Are there additional owners?
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Please Select
Yes
No
Addition owners:
First Name
Last Name
Additional Owner's Date of Birth
/
Month
/
Day
Year
Date
Additional Owner's Relationship to Insured
Is this home a new purchase?
*
Please Select
Yes
No
What is your current (prior) address?
Expected closing date?
*
/
Month
/
Day
Year
Date
What is the purchase price?
*
Is this home currently insured?
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Please Select
Yes
No - lapse less than 30 days
No - lapse more than 30 days
Current (most recent) insurance company?
*
Name of company
Renewal date or requested start date?
/
Month
/
Day
Year
Date
What is your home usage type?
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Owner Occupied - Primary
Owner Occupied - Secondary/Seasonal
Owner Occupied part time & rented to others part time
Rented to Others
Vacant
Rented furnished or unfurnished?
Furnished
Unfurnished
How will your home be rented (pick shortest that will be used)?
*
Annually
Monthly
Weekly
Nightly
Other
Type of home?
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Single Familiy (1 unit)
Townhouse/Rowhouse (multi units)
Condo Unit
Duplex (2 units)
Triplex (3 units)
Quad (4 units)
Other
If mobile/manufactured STOP - this is not the correct form!
If condo unit, what floor is the unit on?
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How many stories tall is the building?
*
What year was your home built?
*
Roof Material
*
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3-tab shingle
Architectural Shingle
Metal
Clay Tile
Other
Roof shape?
*
Gable
Hip
Gable & Hip
Flat
Mansard
I don't know - show me a picture
Other/Unknown
Any solar panels anywhere on home or property?
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Yes
No
Where are the solar panels?
Please Select
Roof
Detached Structure
Yard
Other
How many total solar panels are there?
Have there been any updates to Roof, HVAC, Water Heater, Electrical, or Plumbing since home was originally built?
Please Select
Yes
No
What year have the follow been updated? (N/A if does not apply)
Year
Roof (IMPORTANT)
HVAC
Water Heater
Electrical
Plumbing
What is the heated square footage of your home?
*
How many stories is your home?
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1
1.5
2
2.5
3
Other
How many bedrooms and bathrooms?
*
Foundation Type?
*
Slab
Crawlspace
Basement
Pilings/Stilts
Other
Construction type?
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Please Select
Wood frame - built on site (most common)
Wood frame - moved to this site
Metal frame
Solid brick or concrete blocks
Solid poured concreate / ICF
Modular
Mobile/Manufactured
Other
Mobile/Manufactured STOP - this is the wrong form.
Exterior Wall Material?
*
Please Select
Vinyl
Hardiboard/Hardiplank
Masonry Veneer (brick)
Stone
Wood
Mixed brick with other
Stucco on wood
Stucco on concrete board
Stucco on ICF
Other
If more than one, choose most prevalent.
What type of flooring do you have in your house? If multiple, please give an estimate on % of each kind.
Should equal 100%
Is there a fireplace?
Please Select
No
Yes - natural gas
Yes - propane
Yes - wood
Yes - other
Size of Attached Garage?
*
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No garage
1 car
1.5 car
2 car
2.5 car
3 car
3.5 car
4 car or more
Carport/Other
Are there any screened enclosures or porches?
*
Please Select
Yes
No
Screened enclosures or porches
Covered or Not
Screened or Not
Location
Size (sq ft)
Porch or Patio 1
Covered
Not Covered
Screened
Not Screened
Ground floor
2nd floor
3rd floor
Other
Porch or Patio 2
Covered
Not Covered
Screened
Not Screened
Ground floor
2nd floor
3rd floor
Other
Porch or Patio 3
Covered
Not Covered
Screened
Not Screened
Ground floor
2nd floor
3rd floor
Other
Other
Covered
Not Covered
Screened
Not Screened
Ground floor
2nd floor
3rd floor
Other
Are there any Detached Structures such as shed, fence, garage, pool, etc?
*
Please Select
Yes
No
Detached Structures? (select all that apply)
Garage
Shed
Fence
In-ground pool
Gazebo
Pergola
Barn
Pool house
Other
Is there or will there be a mortgage?
*
Please Select
Yes - insurance escrowed
Yes - not escrowed (paid by policyholder)
No
Unknown
Let's get you those discounts! (check all that apply)
*
Monitored Central Burglar Alarm
Monitored Central Fire Alarm
Security cameras with smart phone app (ring, blink, arlo, etc.)
Whole-house generator
Tankless Water Heater
Automatic water shut-off valve
You are active or retired military
You are a first responder (fire, ems, police)
None of these apply
Things we need to know about. (check all that apply)
*
Filed for bankruptcy, foreclosure, repossession, or short sale in the past 5 years
Had home insurance canceled, non-renewed, or denied coverage
The property is located on more than 5 acres
The home is built OVER water
The property had sink hold activity
There is a swimming pool, hot tub, or trampoline
Filed an insurance claim for any property in the last 5 years
We have (any) pets
None of these apply
List type and breed of all pets.
*
How is the pool &/or hot tub secured?
*
Please Select
POOL / HOT TUB is completely enclosed with a fence to code
POOL / HOT TUB is completely in a screened enclosure
Only a HOT TUB and it has a lockable cover
POOL / HOT TUB has no fence or other protection
Other / Not listed
If you have a pool or hot tub that is not protected, it will be difficult to find competitive insurance for you!
Do you have a trampoline?
*
Please Select
Yes
No
If you have a trampoline (period) it will be difficult to find competitve insurance for you! Are willing to get rid of it?
Prior claim detail.
location address
cause of loss (fire, theft, wind, etc.)
date of loss
$ amout paid
1st claim
2nd claim
3rd claim
4th claim
Would you like prices on any of the following coverages or policies?
*
Yes
No
Other/Notes
Flood Insurance
Earthquake Insurance
Auto Insurance
Umbrella Insurance
Boat / Motorcycle / Golf Cart / RV / Trailer / ATV / EBike / Riding Mower / etc.
Jewelry, Guns, Art, Silverware/Goldware or other type of insurance
Any additional notes you would like us to know?
Please upload current declarations page or helpful documents here.
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