1.) Client Information
Name
Date of Birth
Marital Status
...
Married
Single
Divorced
Widowed
Civil Union
Education
...
College Degree
Some College
Graduate Degree
Vocational/Trade School
HS Diploma/GED
No Diploma/GED
Occupation
Phone Number
Email
Location Address
Mailing Address (if different)
Previous Address (if less than 3 yrs at current residence)
Settlement / Renewal Date
2.) Property Information
Dwelling Type
...
Single Family
Condo
Townhouse/Rowhouse
Duplex
Manufactured Home
Mobile Home
Detached
Construction
...
Frame
Masonry
Log Home
Stucco
Steel
Exterior Type
...
Siding-Vinyl
Siding-Alum Or Metal
Siding-Hardboard
Siding-Board & Batten
Siding-Cedar
Wood Shingle/Shake
Siding Log
Stucco
Brick-Veneer
Brick-Solid
Stone-Veneer
Stone-Solid
Concrete Block
Year Built
Square Footage
Residence Use
...
Primary
Secondary
Rental
Vacant
Any home-sharing (ie, Airbnb)
If yes, Please Answer the Following 3 Questions
Part of Home
...
Entire Home
Room Or Floors In Home
Other Structures(Garage)
Frequency
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Daily
Weekly
Monthly
6 Months+
Both
Number of Calendar Days
...
1-14 Days
15-30 Days
31-60 Days
61-90 Days
91-180 Days
181+ Days
Purchase Date
Distance to Fire Hydrant
..
Less Than 1,000 Feet
Greater Than 1,000 Feet
Distance to Fire Department
..
0-3 Road Miles
3-5 Road Miles
5-7 Road Miles
7+ Road Miles
Name of Responding Fire Department
Distance to Coastline
If Yes, Dog Breed/Other Pet Description(s)
Any losses in the last 5 years?
If Yes, Please Provide Details Below
Date
Cause of Damage
Amount Paid by Company for Claim?
3.) Detailed Property Information
Foundation Type
...
Basement-Unfinished
Basement-Finished
Crawl Space
Slab
Elevated-Piers/Pillings
If Finished Basement – % finished
Number of baths
Full
Half
Roof Type/Roof Material
...
Shingles-Architectual
Shingles-Asphalt 3 tab
Metal
Tile
Slate
Cedar Shakes
Wood
Other
Age of Roof
Type of Heating System?
...
Electric
Oil
Propane
Natural Gas
Other
If Other Describe
If Oil, Location of Tank?
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Above Ground
Below Ground
Basement
If Other, What Type
Year systems updated
Year Heating System Updated
Year Plumbing Updated
Manufacturer of Electric Panel Box
Alternate Heat Source
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None
Woodstove
Pellet Stove
Propane Heater
Alternate Heat Professionally installed?
Trampoline
...
No
Yes-With Net
Yes-No Net
Swimming Pool
...
No
Yes-Inground/Fenced
Yes-Inground/Unfenced
Yes-Above Ground
Slide/Diving Board
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No
Yes-Diving Board
Yes-Sliding Board
Yes-Slide/Dive
Sump Pump
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No
Yes
Yes-W/Battery Backup
Garage
...
Attached
Detached
Built-In
Sq Ft
Monitored Alarm System
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No
Yes- Central Fire & Burglary
Yes- Central Fire Only
Yes- Central Burglary Only
If Yes, how many & location?
Any business on premises?
If yes, type of business
Is business insured elsewhere
If yes, Where
Do you have any items that need scheduling?
If yes, description & value
Mortgage Company Name & Address
4.) Current Coverage
Current Insurance Company
Current Dwelling Limit $
Current Deductible $
Do you currently have flood insurance on this property?
If yes, Current Insurance Company
Submit Request