Byron Pelt Insurance - Property Insurance Intake Form 04 2024 Rev

PROPERTY INSURANCE

DISCOVERY FORM
CURRENTLY INSURED*
EXPIRATION DATE OF CURRENT POLICY/CLOSING DATE OF NEW PURCHASE*

MonthDayYear
PRIMARY PROPERTY OWNER*
individual name, not name of Trust/LLC/Corp
DATE OF BIRTH*

MonthDayYear
EMAIL ADDRESS*
BEST CONTACT NUMBER*
Please enter a valid phone number.
PERMISSION TO SEND QUOTE/POLICY UPDATES VIA TEXT?*
SS# (OPTIONAL)
CO-OWNER OF PROPERTY
CO-OWNER DATE OF BIRTH

MonthDayYear
Date
CO-OWNER EMAIL ADDRESS
CO-OWNER BEST CONTACT NUMBER
CO-OWNER BEST CONTACT NUMBER
Please enter a valid phone number.
SS# (OPTIONAL)
ENTITY NAME IF TITLE TO PROPERTY IS HELD BY LLC/TRUST/CORPORATION
NOTE: INSURED NAME MUST MATCH NAME OF DEEDED OWNER
CURRENT MAILING/RESIDENCE ADDRESS*

Street Address Including Unit #

Street Address Line 2

CityState

Zip Code
ADDRESS OF PROPERTY TO BE INSURED BY THIS POLICY*

Street Address

Unit/Suite/Apt/Condo Number

CityState

Zip Code
HAVE YOU FILED ANY CLAIMS ON ANY PROPERTIES YOU OWN IN THE PAST 3 YRS?*
ANY CLAIMS FILED ON ANY OWNED PROPERTIES
CLAIMS FILED DETAILS
DESCRIBE TYPE OF LOSS AND TOTAL PAID
CURRENT CARRIER ON PROPERTY TO BE INSURED (N/A IF NEW PURCHASE)*
NAME OF COMPANY WITH ACTIVE POLICY IN FORCE
HOME TYPE*

SINGLE FAMILY/DETACHED HOMETOWNHOME/ATTACHED HOMECONDOMINIUMMOBILE/MANUFACTURED HOME
OCCUPANCY*

PRIMARY (Full-Time Resident)SECONDARY (Never Rented/Occasional Use)SEASONAL (Never Rented/Unoccupied > 3 mos.)SECONDARY/RENTAL (Secondary Home with Rental Exposure)RENTAL ONLY (Short and/or Long Term Rental Only)
CURRENT POLICY LIMIT / DESIRED AMOUNT OF COVERAGE (NOTE: OUR SYSTEM WILL GENERATE A REPLACEMENT COST OF THE HOME BASED ON CURRENT CONSTRUCTION COSTS*
CURRENT AMOUNT CAN BE FOUND ON DECLARATIONS PAGE
ALL OTHER PERIL POLICY DEDUCTIBLE*

$1,000$2,500$5,000$10,000
WIND/HURRICANE DEDUCTIBLE*

2%3%5%10%
WIND MITIGATION INSPECTION COMPLETED IN LAST 5 YEARS*
MUST BE A COMPLETED FORM OIR-B1-1802
4- POINT INSPECTION COMPLETED IN LAST 3 YEARS*
FL LICENSED HOME INSPECTOR 4-POINT FORM
SECURITY/PROTECTION SYSTEMS*

SMOKE DETECTORS/FIRE EXTINGUISHERS/DEADBOLT LOCKSBURGLARY/THEFT (DOOR/MOTION SENSORS, CAMERAS)FIRE/SMOKE (CENTRAL FIRE ALARM SYSTEM)WATER (LEAK DETECTION SYSTEMS, VALVE SHUT-OFF SYSTEM)BUILDING SPRINKLER SYSTEM CERTIFIED/INSPECTED IN LAST YEAR
SYSTEMS LISTED ABOVE MONITORED BY THIRD PARTY (ADT, SIMPLISAFE, ETC)
SUBMIT PROOF FOR DISCOUNT
HOME/COMMUNITY ACCESS*

SINGLE ENTRANCE IN/OUT OF COMMUNITYSECURITY GATE - CALLBOX/PASSKEY/PASSCODE ACCESSFULL TIME SECURITY/ATTENDANT AT ENTRANCE
ANY OF THE FOLLOWING FULLY REPLACED IN LAST 10 YEARS (select all if year of home if less than 10 years*

ROOFWATER HEATERCIRCUIT BREAKERHVACSYSTEM UPDATES UNKNOWN
YEAR ROOF WAS REPLACED
YEAR WATER HEATER WAS REPLACED
YEAR CIRCUIT BREAKER WAS REPLACED
YEAR HVAC WAS REPLACED (IF MULTIPLE UNITS, DATE OF EARLIEST REPLACEMENT
ARE THERE ANY OF THE FOLLOWING EXPOSURES?

ANIMALS/PETSINGROUND/ABOVE GROUND POOLTRAMPOLINESPA/HOT TUBSCREENED PORCHOUTDOOR KITCHEN/FIREPLACE
IS THERE AN ACTIVE FLOOD POLICY IN EFFECT FOR THIS PROPERTY*
SUBMIT MOST RECENT FLOOD ELEVATION CERTIFICATE, IF AVAILABLE
WOULD YOU LIKE A QUOTE FOR UMBRELLA/EXCESS LIABILITY POLICY QUOTE*
SHORT TERM RENTAL QUESTIONNAIRE
HOW MANY WEEKS PER YEAR DO YOU AND YOUR IMMEDIATE FAMILY OCCUPY THE RENTAL?*
WHAT IS THE MINIUM NUMBER OF NIGHTS REQUIRED TO RENT?*
HOW MANY WEEKS PER YEAR IS YOUR PROPERTY RENTED?*
WHAT IS THE AVERAGE RENTAL RATE PER NIGHT?
HOW IS THE RENTAL MANAGED?*
NAME OF LOCAL MANAGEMENT COMPANY/POINT PERSON?
ADDRESS, PHONE NUMBER AND EMAIL FOR PROPERTY MANAGER?
DOES THE THIRD PARTY NEED TO BE LISTED ON YOUR POLICY?
HOW ARE YOUR RENTALS OBTAINED?
VRBO, AirBNB, Direct Booking Sites, Referrals, etc.
DO YOU HAVE A PROCESS FOR SCREENING POTENTIAL RENTERS?
Credit Check, Social Media Research, Copy of Driver License, etc.
DO YOU REQUIRE ANY OF THE FOLLOWING?

INSURANCEDAMAGE DEPOSITLIABILITY WAIVEROther
DO YOU HAVE ANY EMPLOYEES (MAIDS/GROUNDSKEEPER, CARETAKTER)?
Name*

First NameLast Name
Signature*

Clear
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

PROPERTY INSURANCE

SHORT TERM RENTAL QUESTIONNAIRE