First Name* What is your first name? *
Last Name* What is your last name? *
Insured 1 - Phone Number* What is your preferred phone number? *
Primary Email* What is your email address? *
Insured 1 - Occupation What is your occupation?
Insured 1 - Employer What is the name of your employer?
Insured 1 - Date of Birth* What is your date of birth? *
MM slash DD slash YYYY
Insured 1 - Marital Status What is your marital status?
Single Married Domestic Partnership Engaged Divorced Widowed
Spouse - Full Name What is your spouse's full name?
Domestic Partner - Full Name What is your partner's full name?
Fiancé - Full Name What is your fiancé's full name?
Other Insured's Occupation & Employer Please enter their occupation and employer name:
Insured 2 - Date of Birth Please enter their date of birth.
MM slash DD slash YYYY
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). *
Property Type Is this a Condominium or Cooperative?
Property Type Other What type of property is this?
New Purchase? Are you in the process of purchasing this condo/co-op?
Purchase Price? What is the purchase price?
New Condo / Coop Closing Date? What is the closing date?
MM slash DD slash YYYY
Current Insurer What is the name of your current insurance company?
Desired Effective Date? When would you like coverage to start?
MM slash DD slash YYYY
New Purchase Occupancy Please select the intended occupancy of the condo/co-op you are purchasing.
New Purchase Occupancy other Please describe the intended occupancy of the home you are purchasing.
Owned Condo/Coop Occupancy Please select the occupancy of this property.
Owned Condo/Coop Occupancy other What is the occupancy of this condominium/cooperative?
Months Occupied? Please select the months this unit will be occupied. (Select all that apply)
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Current Home Address What is your current home address?
Primary Home Address What is your primary home address?
New Purchase - 3 Yrs at Current Residence Have you lived at your current address for three or more years?
Owned Home - 3 Yrs at Current Residence Have you lived at your primary home address for three or more years?
New Purchase - Previous Home Address Please provide the address where you lived prior to your current address?
Owned Home - Previous Home Address Please provide the address where you lived prior to your current address?
Major Renovation Will you renovate this condo/co-op before moving in?
Renovation Budget? What is the renovation budget?
Renovation Time Frame How long will the renovation take?
Renovation Description Please provide a brief description of your renovation plans.
Condo/Coop Rental Frequency Please select the frequency of rentals for this Condo/Co-op.
New Purchase Mortgage? Will there be a mortgage?
Bank/Lender Name? What is the name of the bank providing the mortgage?
New Purchase Bank Contact? Who is your contact at the bank?
New Purchase Bank Phone? What is the phone number for your contact at the bank?
New Purchase Bank Email? What is the email address for your contact at the bank?
Existing Home Mortgage? Is there a mortgage?
Current Mortgage Bank Name? Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Current Mortgage Bank Address? Please enter the bank address, if convenient.
Current Mortgage Loan Number? Please enter the loan number, if convenient.
Trust or LLC Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?
Legal Entity Information Legal Entity Name What is the name of the legal entity?
Legal Entity Type What type of legal entity is it?
Limited Liability Company (LLC) Trust Limited Liability Partnership (LLP) Family Limited Partnership (FLP) Other
Legal Entity Type Other Please enter the type of legal entity:
Legal Entity Mailing Address Match? Is the mailing address for the legal entity the same as the location address for this proposal?
Legal Entity Mailing Address What is the mailing address for the legal entity?
Legal Entity Owned Assets Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Legal Entity Beneficial Owners Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
Legal Entity Purpose What is the purpose or intent of the entity?
Legal Entity Income Generation? Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business?
Legal Entity Income Generation Details Please provide details about the income generation and business conducted by this entity.
Legal Entity Income Generation Other Does the entity generate income in any other ways?
Legal Entity Income Generation Other Details Please provide details about how this entity generates income.
Legal Entity Asset Ownership Other Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Legal Entity Other Assets List Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Legal Entity Employees Does the entity have any employees?
Legal Entity Employee Names and Occupations Please list the name and occupation for each of the employees:
Legal Entity Payroll Info Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Legal Entity Insurance Policies Does the entity maintain any other insurance policies?
Legal Entity Other Insurance Coverage Info Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Residence Details Alarm System Does this condo/co-op have an alarm system?
Alarm System Components Select the components of your alarm system.
Alarm system other What other components do you have in your alarm system?
Unit Fire Sprinklers? Does this unit have fire sprinklers?
Unit Square Footage? What is the square footage of this unit? (Under air)
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Condo/Co-op Year Built What year was this condo/co-op built?
What year was this condo/co-op built? What year was this condo/co-op built?
Condo/Co-op Total Stories? How many stories does this building have?
Unit Floor Number? On which floor is this unit located?
System/features Updates Select the elements of this condo/co-op that have been updated.
System/features updates other What other updates have been done to your home?
Electrical update year What year was the electrical updated?
Plumbing update year What year was the plumbing updated?
Heating system update year What year was the heating system updated?
Windows update year What year were the windows updated?
Roof Age What is the age of the building's roof?
Roof Type What type of roof does this building have?
Roof Type Other Please provide a description of this building's roof type.
Four Point Inspection? Has a 4-point inspection been done on this condominium/cooperative?
Four Point Inspection Upload Please upload a copy of the 4-point inspection, if available.
Wind Mitigation Inspection? Do you have a windstorm mitigation inspection certificate for this condominium/cooperative or for the association?
Windstorm Mitigation Certificate Upload Please upload a copy of the windstorm/wind mitigation certificate, if available.
Previous Renovations? Do you know of any previous renovations done to this unit?
Previous Renovation Information Please share the information you have about any previous renovations in this unit.
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...)
Mold/Fungi Insurance Proposal? Would you like to include mold/fungi coverage in your proposal?
Have you had any insurance claims in the last five years? ** Have you had any insurance claims in the last five years? *
Please provide details about any insurance claim(s) in the last five years. ** Please provide details about any insurance claim(s) in the last five years. *
Condo/Coop claims?* Have there been any insurance claims at this location in the last five years? *
Condo/Coop Claim Details* Please provide details about any insurance claim(s) in the last five years. *
Flood Insurance Proposal?* Would you like a flood insurance proposal for this condo/co-op? *
Flood Insurance Information Substantially Improved? Has the condo/co-op been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Machinery Location Where is the machinery that services this unit located? (Air conditioning, Furnace, Boiler, etc...)
Machinery Location Other Please describe where the machinery for this residence is located.
Contents Location Where is your personal property kept at this location?
Ground level and above Basement and above Elevated floor and above Other
Contents Location Other Please describe where the personal property is kept at this location.
Flood Vents Does this condo/co-op have flood vents?
Flood Insurance Policy Is there a flood insurance policy in place today?
Flood Policy PDF Please upload a copy of the Flood insurance policy, if available.
Policy Cancellation Is the flood policy being cancelled or non-renewed?
Policy Cancellation Description Please share the insurer's reason for cancelling or non-renewing your policy.
Elevation Certificate Do you have an elevation certificate for the building from the condo/co-op association?
Elevation Certificate File Upload Please upload a copy of the elevation certificate
Flood claims?* Have there been any flood insurance claims in this unit? *
Claims Payments Over $5,000 Have you been paid over $5,000 on any flood claims in the last 10 years?
Flood claim details* Please provide details about the flood insurance claims at this residence.
Documents and Comments Documents Upload Please use this field to upload any relevant insurance documents. (I.e. By-laws of the association, current policy declarations pages, etc...)
Additional Remarks Please enter any additional remarks in the space below.
Referral Source? How did you hear about us?
Current customer Referred by... Google search Agency's website Email newsletter Facebook Instagram Twitter Other
Please share who referred you to us. Please share who referred you to us.
Please share what you typed into Google. Please share what you typed into Google.
Please share how you heard about us. Please share how you heard about us.
Consent* 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.
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