Protect your most valuable assets — get home, condo or renter's insurance quotes. Homeowners insurance is designed to pay for damages to your home and its contents.   Homeowners insurance is a package policy consisting of different types of coverage for the house, its contents, additional living expenses, personal liability claims against the policyholder and other members of the household, and medical payments to others. Insurance policies are also available for Condos and Town homes.

 
  Personal Information

1

   First Name Middle Initial
                   
2   Last Name        
                   
 3   Street Address City  
                   
 4   State Zip Code    
                   
5   Email Address County    
   
6   Day Phone   Fax    
       
7   Eve Phone    
     
8   Social Security Number  *
     
9
  Date of Birth:
 *
     
10   Spouse Social Security Number:  
     
11   Spouse Date of Birth:
     
12   Dwelling amount   .00
     
13   Property Coverage Deductible
     
14   Comprehensive Liability Amount
     
15   Medical Payments
     
16   Guaranteed Replacement Cost Coverage Yes No
     
17   Water Backup Coverage Yes No
     
18   Type Of Home
     
19   Year home built
     
20   Construction
     
21   Type of Roof
     
22   Year the roof was last upgraded:
     
23   Ground floor area (sq ft.)
     
24   Total basement area (sq ft.)
     
25   Number of Stories
     
26    Personal Property Amount
  (Applicable for condo owners or renters.)		 $ .00
     
27   Distance to nearest fire hydrant
     
28   Distance to nearest fire station
     
29   Any Business conducted on premises? Yes No
     
30   Inside or Outside of City?
     
31   Type of Alarm
     
32   Sprinklers? Yes No
     
33   Animals? Yes No
     
34   If yes, please provide breed
     
35   Number of Bathrooms
     
36   Attached Garage
     
37   3 Wall Addition? (square feet)
     
38   Percent of basement finished %
     
39   Family Room Yes No
     
40   Sun Room Yes No
     
41   Den Yes No
     
42   Separate Dining Room Yes No
     
43   Any hardwood Floors Yes No
     
44   Central Air Conditioning Yes No
     
45   Decks (total square feet)
     
46   Porches (total square feet)
     
47   Large Laundry Room Yes No
     
48   Large foyer Yes No
     
49   Central Vac Yes No
     
50   Video entry system Yes No
     
51   Sauna Yes No
     
52   Hot Tub Yes No
     
53   Jacuzzi bath Yes No
     
54   Dishwasher Yes No
     
55   Trash Compactor Yes No
     
56
  Primary heating source:
 *
     
57
  Year the heating source was last upgraded:
 *
     
58
  Alternate heating source:
 Yes No *
     
59   Foundation *
     
60
  Electric circuit breaker:
 Yes No *
     
61   Deadbolt: Yes No *
     
62
  Fire extinguisher:
 Yes No *
     
63   Smoke alarm: Yes No *
     
64   Central alarm: *
     
65   Swimming pool: Yes No *
     
66   If yes, type:
     
67
  Is homeowner's insurance currently in force?
 Yes No *
     
68
  If yes, with which company:
     
69
  What is the expiration date:
     
70
  Have you been declined, canceled, or not renewed in the last 
  3 years?
 Yes No *
     
71
  If yes, what was the reason:
     
72
  Have you had any homeowner's claims in the last 3 years?
*
     
73
  Is this a new purchase?
     
74
  If yes, when is the closing date:
     
73 Is there any pre-existing damage to the risk?
     
74 If there is a woodstove, was it professionally installed?
     
75 Is the dwelling located within 400 feet of brush area, forested area or any area of increased fire hazard?
     
76 Is this dwelling vacant or is it located in a neighborhood with 3 or more vacant or condemned homes?
     
77 Is this dwelling in foreclosure?
     
78 Is this dwelling located in a commercial or industrial location?
     
79 Is the primary source of heat thermostatically controlled?
     
80 Does the dwelling have unusual or irreplaceable construction (including EFIS construction), cantilever construction, including dwelling on posts, stilts, and pilings (except where the result is required or authorized by current building codes to be elevated on posts/piers/pilings and there is no slope/stilts), or is a log or metal home, or utilizes asbestos siding/roofing?
     
81 Does the dwelling have copper or PVC Plumbing?
     
82 Are there any roommates or boarders in the home?
     
83 Do you show pride of ownership and properly maintain the premises of the dwelling?
     
84 Are any abandoned, non-operational, not regularly used, or commercial vehicles stored at this location?
     
85 Do you employ any domestic workers more than 10 hours per week at this dwelling premises?
     
86 Does the occupant of the dwelling have any horses, cows, sheep, chickens, or any other farm or exotic pets?
     
87 Has the applicant filed for bankruptcy in the last 10 years?
     
88 Is the dwelling owned/titled in the name of a church or non-profit organization or association?
     
89 Is this property located in a landslide or mudslide area?
     
90 Are there any trampolines at this location?
     
91 Is there a barn or other farming/ranching equipment on the premises?
     
92 Do you have legal title to the land on which the premises resides or a long term ground lease with more than 50 years remaining on the term of the lease?
     
93 Is this property located in a gated community?

COMMERCIAL PROPERTY QUESTIONS:
 
94

Business entity
     
95 Completely describe the operations at this location, including the number of buildings and the number of units per building.
     
96

How long has applicant been in this type of business?
     
97

How long has applicant been at this location?
     
98

Describe any commercial tenants, including related square footage
     
99

Number of commercial units currently vacant
     
100

Describe all adjoining or adjacent occupancies and/or vacancies
     
101

Total annual apartment rental receipts
     
102

Total annual commercial occupancy receipts
     
103

Number of apartment units (including manager’s unit)
     
104

Parking area sq ft or total number of parking spaces
     
105

Do units open to common interior hallways?

 Yes No *
     
106 Does the building owner/manager live on the premises? Yes No *
     
107

Describe all unusual operations or business practices not customary to this type of business.

     
108  Year policy history
     
109

Loss history for the last 4 years (include claims reported, unreported, and know occurrences which may result to claims)

Description    Date   Amount   Open/Closed
     
110

Has applicant had a fire loss at this or other property of business within 10 years?

 Yes No *
     
111 If yes describe
     
112

Is the subject risk currently insured for both Property and Liability?

 Yes No *
113 Do you conduct business from your home? Yes No *

 
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