Residential Property Insurance

PERSONAL LINES APPLICANT
Required Insured Information
Insured Name*

First NameLast Name
Named Insured Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Code Description and Name (if applicable)
What is the Value of the Home?*
Named Insured Physical Location Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Named Insured Physical Location same as Mailing Address?*
What is a premium amount to target?*
Current Insurance Carrier:*
Expiration Date of Current Policy
Target Effective Date*

MonthDayYear
Date
Additional Insured Information
Number of Properties to Insure
Example 1 or 3
COVERAGE TYPE
PROPERTY TYPE
Property to be occupied by owner or a renter
Individual (I) o Corp. (C):
Do you live in USA
SECURITY SYSTEMS (Mark with a X where appropriate - If known)
Mailing address (or current if buying a new property)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Prior insurance (Not appilcable if new owner)
Current Policy - Declarations Page

Cancelof
4 Point Inspection

Cancelof
Wind Mitigation Inspection

Cancelof
LENDER, FINANCE INFORMATION
Dwelling Limit*
Personal Property*
Liability
Medical Payments*
Other Structures*
Loss of Use*
AOP Deductible
Hurricane Deductible*
Property Information
SECURITY SYSTEMS (Mark with a X where appropriate - If known)
Year Built
Square Feet
Number of stories
Distance to Hydrant
Fire Burglary Protection
Monitored Burglar Alarm, Monitored Fire Alarm, Combo Alarm
Distance Fire Dpt
Other Water Source
Other Water Source
Roof Last Replaced*
Plumbing Last Replaced*
Electric Last Replaced*
Heating Last Replaced*
Additional Underwriting Information
Is there a swimming pool?*
Is there any bankruptcy?*
Are there any animals on the premises?*
Is this a new home closing?*
Claims Information (last 5 years)*
Comments To Underwriter:
Mitigation Information
Roof Type
Roof Type
Roof to Wall Connections:*
Hurricane Class A Shutters/Impact Glass:*
Distance to Coast (miles to coastline/waterways):*
Florida Building Code*
I certify that the information provided in this form is complete and accurate to the best of my knowledge, information and belief.
Date

MonthDayYear
Date
The parties understand and agree that to the extent that they sign electronically, that their signature is the legally binding equivalent to their handwritten signature. You agree that you will not at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature was or is not legally binding.
This affidavit template is designed to authorize your company or an individual to collect and use information to process quotes with insurance carriers.
Should be Empty:

PERSONAL LINES APPLICANT

Required Insured Information

Property Information

Additional Underwriting Information

Mitigation Information

I certify that the information provided in this form is complete and accurate to the best of my knowledge, information and belief.