Byron Pelt Insurance - Property Insurance Intake 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)*

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

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:*

PRIMARY OWNER EMAIL ADDRESS:*

BEST CONTACT NUMBER FOR PRIMARY OWNER:*

Please enter a valid phone number.Format: (000) 000-0000.

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)*

FULL NAME OF CO-OWNER OF PROPERTY:

CO-OWNER DATE OF BIRTH

Date

CO-OWNER EMAIL ADDRESS

CO-OWNER BEST CONTACT NUMBER:

Please enter a valid phone number.Format: (000) 000-0000.

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?

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*

OCCUPANCY*

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:*

ALL OTHER PERIL POLICY DEDUCTIBLE (Fire, Theft, Water, etc)*

WIND/HURRICANE DEDUCTIBLE*

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:*

SYSTEMS LISTED ABOVE MONITORED BY THIRD PARTY (ADT, SIMPLISAFE, ETC)

SUBMIT PROOF FOR DISCOUNT

DESCRIBE CONTROLS/ACCESS TO YOUR HOME OR UNIT:*

ANY UPDATES TO THE FOLLOWING IN THE LAST 10 YEARS? (Leave blank if updates unknown or home is newer)*

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?

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