Insurance Application Questionnaire
Which Term Brokers agent are you working with?
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Michael
Jeremiah
Lauren
Emily
Zehra
Unknown
Name
*
Email
*
Phone Number
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Marital Status
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Single
Married
Divorced
Widowed
Date of Birth
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-
Month
-
Day
Year
Date
Date of Birth
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SSN
*
Occupation/ Employer
*
Second Named Insured
First Name
Last Name
Second Named Insured Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
Second Named Insured Phone Number
-
Area Code
Phone Number
Second Named Insured Email address
example@example.com
Second Named Insured Occupation and Employer
Second Named Insured Work/Other Phone Number
-
Area Code
Phone Number
Property Address to be insured:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Residential/ Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupancy?
Primary
Secondary
Short Term Rental (1 day-6 months)
Long Term Rental (yearly)
Secondary/Rental
Will this policy be for a closing?
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Yes
No
Is coverage currently in force on this property?
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Yes
No
Please attach your current declarations page
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Browse Files
Cancel
of
When do you need coverage to begin?
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-
Month
-
Day
Year
Date
Estimated Closing Date
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-
Month
-
Day
Year
Date
Who is your mortgage loan officer/ processor?
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Loan officer/ Processor Phone Number
*
-
Area Code
Phone Number
Loan Officer/ Processor E-mail address
*
example@example.com
Title Company
Title Company Email
example@example.com
Title Company Phone Number
-
Area Code
Phone Number
Occupancy of Home?
*
Primary
Secondary
Short Term Rental
Long Term Rental
Rental Duration (if applicable)
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Nightly
Weekly
Biweekly
Monthly
Foundation Type
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Slab
Crawlspace
Open (piers or pilings)
Basement
Do you have a completed 4 point inspection?
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Yes
No
It is scheduled
My home is 2000 built or newer and doesn't require this
Do you have a completed wind mitigation inspection?
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Yes
No
It is scheduled
My home is a new build (2015-current year) and doesn't require it
When are your inspections scheduled?
-
Month
-
Day
Year
Date
Attach wind mitigation inspection
Browse Files
Cancel
of
Attach 4 point inspection
Browse Files
Cancel
of
Do you have solar panels OR will you be adding solar panels?
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Yes
No
Age of roof
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Roof material
Roof Material
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Shingle
Metal
Tile
Other
Age of water heater
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Location of water heater
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Age of HVAC
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Any farming or business activity at this location?
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No
Yes
Is the property located on 5 or more acres?
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No
Yes
Is there a pool?
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No
Yes
is it surrounded by a screen enclosure or 4’ locking fence?
Screen
Fence
Both
None
Any Diving Boards or Slides?
Diving Board
Slide
Both
None
Is there a trampoline/skateboard ramp on premises or will one ever be installed?
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No
Yes
Are there any animals on premises?
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No
Yes
Breeds?
*
If yes, do any animals have a history of biting?
Is there an HOA that covers the exterior unit (townhomes and condos only)?
Yes and I have a copy of the document to send
Yes and I do not have a copy of the document to send
No, my insurance will need to cover the entirety of the property
This doesn't apply to me
I am not sure
Is the risk currently, or was it purchased as a short sale or foreclosure?
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No
Yes
Any unrepaired damage to or renovations/construction on the insured location?
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No
Yes
Will there be any renovations/ construction on the dwelling within the next 90 days?
Yes
No
Please describe nature of renovations
Any Prior Claims in the last 5 years?
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No
Yes
Date of Claim(s)
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-
Month
-
Day
Year
Date
Claim(s) Closed?
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No
Yes
Brief Description of claim(s)
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You or your co-applicant convicted of arson?
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No
Yes
You or your co-applicant had any foreclosure, repossession or bankruptcy, DUI Lawsuits last 5 years?
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No
Yes
Details of prior , repossession or bankruptcy, DUI, Lawsuit
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Have you ever been cancelled, non-renewed, or declined forinsurance coverage?
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No
Yes
Any recreational vehicles on the property (dirtbikes, motorcycles, ATVs,)
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No
Yes
Year/ Made/ Model of Recreational Vehicles
Is property located within 300 feet of a commercial property?
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No
Yes
Will property be owned under a business name?
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No
Yes
Name of Corporation, Trust, or LLC
*
I would like additional quotes on:
Life Insurance
Flood Insurance
Auto Insurance
Boat Insurance
RV Insurance
Who referred you to Term Brokers?
*
My Realtor
My Loan Officer
An existing or prior Term Brokers client
Facebook/Social Media
Other
If the carrier has a paperless option for policy documents, would you like to be enrolled in that?
Yes
No
Referral Name
I understand and agree to all the coverage as listed on the quote provided.
*
I understand
I affirm that each question is accurate to the best of my ability and understand any errors may result in cancellation or claim denials.
*
I affirm
Signature
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Submit
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