Byron Pelt Insurance - Property Insurance Intake Form

PROPERTY INSURANCE

DISCOVERY FORM
ARE YOU CURRENTLY INSURED OR IS THIS A NEW PURCHASE?*
WHAT DATE DO YOU NEED COVERAGE? (Expiration date of current policy or expected closing date)*

MonthDayYear
IS TITLE TO SUBJECT PROPERTY HELD IN THE NAME OF ANY TYPE OF TRUST AGREEMENT OR LLC/CORPORATION/PARTNERSHIP?*

YESNO
LEGAL NAME OF ENTITY THAT WILL OWN PROPERTY:*
individual name, not name of Trust/LLC/Corp
FULL NAME OF PRIMARY PROPERTY OWNER:*
individual name, not name of Trust/LLC/Corp
PRIMARY OWNER DATE OF BIRTH:*

MonthDayYear
PRIMARY OWNER EMAIL ADDRESS:*
BEST CONTACT NUMBER FOR PRIMARY OWNER:*
Please enter a valid phone number.
PERMISSION TO SEND QUOTE/POLICY UPDATES VIA TEXT MESSAGE?*
PRIMARY OWNER SOCIAL SECURITY NUMBER: (OPTIONAL, but may be required)
IS THERE A SECONDARY OWNER? (SPOUSE/PARTNER/CO-OWNER)*

YESNO
FULL NAME OF CO-OWNER OF PROPERTY:
CO-OWNER DATE OF BIRTH

MonthDayYear
Date
CO-OWNER EMAIL ADDRESS
CO-OWNER BEST CONTACT NUMBER:
Please enter a valid phone number.
CO-OWNER SOCIAL SECURITY NUMBER: (OPTIONAL, but may be required)
ENTER YOUR CURRENT RESIDENCE ADDRESS:*

Street Address Including Unit #

Street Address Line 2

CityState

Zip Code
IS THE CURRENT ADDRESS THE SAME AS THE ADDRESS TO BE INSURED?

YESNO
ENTER THE ADDRESS OF THE PROPERTY TO BE INSURED:*

Street Address Including Unit #

Street Address Line 2

CityState

Zip Code
ENTER THE ADDRESS OF THE PROPERTY TO BE INSURED:*

Street Address

Unit/Suite/Apt/Condo Number

CityState

Zip Code
HAVE YOU FILED ANY CLAIMS ON ANY PROPERTIES YOU OWN IN THE LAST 5 YRS?*
INCLUDE ANY CLAIMS FILED ON YOUR PRIMARY OR SECONDARY RESIDENCE, AS WELL AS, ANY RENTAL PROPERTIES YOU OWN
CLAIMS FILED DETAILS
DESCRIBE TYPE OF LOSS AND TOTAL PAID
WHAT IS THE NAME OF YOUR CURRENT INSURANCE COMPANY? (Enter "NEW PURCHASE" if you are under contract)*
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 Months or Longer)SECONDARY/RENTAL (Secondary Home with Rental Exposure)RENTAL ONLY (Short and/or Long Term Rental Only)
CURRENT COVERAGE A/DWELLING LIMIT or COVERAGE AMOUNT REQUESTED TO REBUILD: (NOTE: We will complete an estimate of coverage needed based on current market conditions using replacement cost estimating software)*
CURRENT AMOUNT CAN BE FOUND ON DECLARATIONS PAGE
CURRENT COVERAGE C/PERONAL PROPERTY LIMIT or COVERAGE AMOUNT REQUESTED TO COVER CLOTHING, FURNITURE, PERSONAL ITEMS:*

$25,000$50,000$75,000$100,000Agent RecommendationOther
ALL OTHER PERIL POLICY DEDUCTIBLE (Fire, Theft, Water, etc)*

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

2%3%5%10%Other
DO YOU HAVE A CURRENT WIND MITIGATION REPORT?*
MUST BE A COMPLETED FORM OIR-B1-1802
DO YOU HAVE A CURRENT 4-POINT INSPECTION REPORT?*
FL LICENSED HOME INSPECTOR 4-POINT FORM
PLEASE NOTE THE FOLLOWING SECURITY & PROTECTION SYSTEMS IN THE HOME:*

SMOKE DETECTORS/FIRE EXTINGUISHERS/EXTERIOR DEADBOLT LOCKSBURGLARY/THEFT PROTECTION - MONITORED BY A THIRD PARTYFIRE/SMOKE/CARBON MONOXIDE DETECTION - MONITORED BY A THIRD PARTYWATER/LEAK DETECTION SYSTEMS, AUTOMATIC VALVE SHUT-OFF SYSTEMINTERIOR BUILDING SPRINKLER SYSTEM - INSPECTION CERTIFICATE REQUIRED
SYSTEMS LISTED ABOVE MONITORED BY THIRD PARTY (ADT, SIMPLISAFE, ETC)
SUBMIT PROOF FOR DISCOUNT
DESCRIBE CONTROLS/ACCESS TO YOUR HOME OR UNIT:*

SINGLE ROAD IN/OUT OF THE COMMUNITYSECURITY GATE WITH A CALLBOX OR KEY/CODE ACCESSFULL TIME GATE/ACCESS ATTENDANT24 HOUR SECURITY PATROL
ANY UPDATES TO THE FOLLOWING IN THE LAST 10 YEARS? (Leave blank if updates unknown or home is newer)*

ROOFWATER HEATERCIRCUIT BREAKERHVACUPDATES UNKNOWN/NEWER HOME
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?

DOGS/PETS/EXOTIC ANIMALSSWIMMING POOLOUTDOOR PLAYSET/TRAMPOLINESPA/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*

PROPERTY INSURANCE

SHORT TERM RENTAL QUESTIONNAIRE