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Condominium/Cooperative Insurance - Current Client
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What is your first name?
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What is your first name?
What is your last name?
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What is your last name?
What is your preferred phone number?
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What is your preferred phone number?
Please enter your email.
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Please enter your email.
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Date of Birth
Please enter your Date of Birth (MM/DD/YY):
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Please enter your Date of Birth.
Please enter your Date of Birth.
MM slash DD slash YYYY
What is your marital status?
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What is your marital status?
Single
Married
Domestic Partnership
Engaged
Divorced
Widowed
What is your spouse's full name?
What is your spouse's full name?
What is your partner's full name?
What is your partner's full name?
What is your fiancé's full name?
What is your fiancé's full name?
Please enter their occupation.
Please enter their occupation.
Please enter their employer.
Please enter their employer.
Please enter their date of birth.
Please enter their date of birth.
MM slash DD slash YYYY
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Will anyone else be named on this quote?
Will anyone else be named on this quote?
Yes
No
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Other Insured Name
Please enter their name:
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Other Insured Occupation & Employer
Please enter their occupation and employer name:
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Other Insured Date of Birth
Please enter their Date of Birth (MM/DD/YYYY):
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Other Insured Date of Birth
Please enter their Date of Birth:
MM slash DD slash YYYY
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Relationship to Other Insured
What is your relationship to them?
Married
Domestic Partner
Engaged
Family Member (Brother, Sister, Father, Mother, etc.)
Cohabitants / Life Partners
Other
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Relationship Description with Other Insured
Please describe your relationship with them.
Please enter the address of the condo/co-op you would like a proposal for (Include apartment number, if applicable).
*
Please enter the address of the condo/co-op you would like a proposal for (Include apartment number, if applicable).
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
New Purchase?
Are you in the process of purchasing this condo/co-op?
Yes
No
Is this a Condominium or Cooperative?
Is this a Condominium or Cooperative?
Condominium
Cooperative
Other
What type of property is this?
What type of property is this?
Purchase Price?
*
What is the purchase price?
Hidden
Closing Date?
What is the closing date? (MM/DD)
New Condo / Coop Closing Date?
What is the closing date?
MM slash DD slash YYYY
Effective date?
What date do you want this coverage to start?
New Purchase Occupancy
Please select the intended occupancy of the condo/co-op you are purchasing.
Primary residence
Secondary residence
Rented to others (long-term, short-term, or seasonal tenants)
Unoccupied
Vacant (No contents)
Under construction/renovation
Other
New Purchase Occupancy other
Please describe the intended occupancy of the home you are purchasing.
Owned Home Occupancy
Please select the occupancy of this property.
Primary residence
Secondary residence
Rented to others (long-term, short-term, or seasonal tenants)
Unoccupied
Vacant (No contents remain)
Under construction/renovation
Other
Owned Home Occupancy other
What is the occupancy of this home?
Hidden
Current Home Address
What is your current home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Primary Home Address
What is your primary home address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
New Purchase - 3 Yrs at Current Residence
Have you lived at your current address for three or more years?
Yes
No
Owned Home - 3 Yrs at Current Residence
Have you lived at your primary home address for three or more years?
Yes
No
New Purchase - Previous Home Address
Please provide the address where you lived prior to your current address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Owned Home - Previous Home Address
Please provide the address where you lived prior to your current address?
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Major Renovation
Will you renovate this condo/co-op before moving in?
Yes
No
Renovation Budget?
What is the renovation budget?
Renovation Time Frame
How long will the renovation take?
Less than 30 days
1 to 3 months
3 to 6 months
6 to 12 months
1 to 2 years
Please select the frequency of rentals for this Condo/Co-op.
Please select the frequency of rentals for this Condo/Co-op.
Long-Term/Annual Lease
One to Two Months per Year
Summer Rental Property/Weekly
One night to Monthly (Ie. AirBNB, Homeaway.com, etc...
Will there be a mortgage?
Will there be a mortgage?
Yes
No
What is the name of the bank providing the mortgage?
What is the name of the bank providing the mortgage?
Who is your contact at the bank?
Who is your contact at the bank?
What is the phone number for your contact at the bank?
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank?
What is the email address for your contact at the bank?
Is there a mortgage?
Is there a mortgage?
Yes
No
Please enter the bank name, if convenient.
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient.
Please enter the bank address, if convenient.
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Please enter the loan number, if convenient.
Please enter the loan number, if convenient.
Trust or LLC
Is this property owned by a Trust, LLC or Limited Partnership?
Yes
No
Trust or LLC Name
Please enter the name of the Trust, LLC or Limited Partnership:
Alarm System
Do you have an alarm system in your condo/co-op?
Yes
No
Alarm System Components
Select the components of your alarm system.
Heat/Smoke detectors
Burglar motion sensors
Low temperature monitor
Water leak detection
Cellular Back-up
24-hour video surveillance
Gas leak detection
Other
Alarm system other
What other components do you have in your alarm system?
Approximate Square Footage
What is the approximate square footage of this property?
What year was this condo/co-op built?
What year was this condo/co-op built?
Hidden
Year Built
What year was this condo/co-op built?
MM slash DD slash YYYY
Do you have any information that will assist us in estimating the replacement cost of the improvements and betterments?
Do you have any information that will assist us in estimating the replacement cost of the improvements and betterments in this unit? (I.e. Recent renovation costs, ball park construction cost to rebuild the unit, any unique features, etc...)
Yes
No
Not sure
Please share the information you have about the replacement cost of the improvements and betterments in this unit.
Please share the information you have about the replacement cost of the improvements and betterments in this unit.
System Updates
Select the systems that have been updated in the last 10 years.
Electrical
Plumbing
Heating
Roof
Windows
Other
None of the above
Other System Updates
What other systems have been updated?
What would it cost to replace your personal belongings at this location? (I.e. Clothing, furniture, rugs, electronics, etc...)
What would it cost to replace your personal belongings at this location? (I.e. Clothing, furniture, rugs, electronics, etc...)
Do you plan to sell an existing residence? *
*
Do you plan to sell an existing residence? *
Yes
No
I do not own another residence
Please enter the address of the residence you plan to sell.
Please enter the address of the residence you plan to sell.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Would you like a flood insurance proposal for your Condo/Co-op?
Would you like a flood insurance proposal for your Condo/Co-op?
Yes
No
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, etc...)
Please use this field to upload any relevant insurance documents. (I.e. By-laws of the association, current policy declarations pages, etc...)
Drop files here or
Select files
Accepted file types: jpg, gif, png, pdf, tiff, Max. file size: 128 MB, Max. files: 5.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
Consent
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Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
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Amy Sheriden
555555555
http://insuranceagency.com
amy.sheridan@uxmai.com
Amy Sheridan
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