Gallagher Test Form v5.0

What is your first name? **
What is your first name? *
What is your last name? **
What is your last name? *
What is your preferred phone number? **
What is your preferred phone number? *
Please select a description for this number. Primary
Please select a description for this number.
- Mobile
- Office
- Home
What is your email address? **
What is your email address? *
What is your occupation? **
What is your occupation? *
What is your employer name? **
What is your employer name? *
Please enter your date of birth. **
Please enter your date of birth. *
MM slash DD slash YYYY
What is your gender?
What is your gender?
What is your relationship status? **
What is your relationship status? *
Will there be a second named insured? **
Will there be a second named insured? *
- Yes
- No
Please enter their name: **
Please enter their name: *
Please enter their email address?
Please enter their email address?
Please enter their phone number.
Please enter their phone number.
Please select a description for this number. Secondary
Please select a description for this number.
- Mobile
- Office
- Home
Please enter their occupation. **
Please enter their occupation. *
Please enter their employer name. **
Please enter their employer name. *
Please enter their date of birth. **
Please enter their date of birth. *
MM slash DD slash YYYY
What is their gender?
What is their gender?
What is their relationship status? **
What is their relationship status? *
Account Mailing/Billing Address?*
What is your mailing/billing address?

Street Address Address Line 2 City State ZIP Code
Insurance Analysis Goals
What are your goals for this insurance analysis? (I.e. What could be better about your coverage? What is important to you with your insurance? What do you want to make sure we address?)
Personal Insurance Program Structure
Selected Quotes*
Which of the following risks are part of your personal insurance program? (Select all that apply) *
- Location 1
- Location 2
- Location 3
- Location 4
- New Construction/Renovation
- Valuable Collections
- Automobile
- Watercraft
- Toys (ATVs, Golf Carts, Motorcycles, Snowmobiles)
- Personal Cyber Liability
- Personal Excess Liability/Umbrella
(ADVISOR USE ONLY) Select the quoting instructions sections to complete.
(ADVISOR USE ONLY) Select the quoting instructions sections to complete.
- Location 1 Coverage Limits
- Location 2 Coverage Limits
- Location 3 Coverage Limits
- Location 4 Coverage Limits
- New Construction/Renovation Coverage Limits
- Valuable Articles Coverage Limits
- Automobile Coverage Limits
- Watercraft Coverage Limits
- Toys Coverage Limits
- Personal Cyber Liability Limits
- Personal Excess Liability/Umbrella Coverage Limits
Location 1
What is the address of this residence? * home 1*
What is the address of this residence? *

Street Address Address Line 2 City State ZIP Code
Please select the property type for this location? * home 1*
Please select the property type for this location? *
New Home Purchase? * home 1*
Are you in the process of purchasing this home? *
- Yes
- No
Home Purchase Price home 1
What is the purchase price?
What is the closing date? Home 1
What is the closing date?
MM slash DD slash YYYY
When do you need this coverage to start? Home 1
When do you need this coverage to start?
MM slash DD slash YYYY
What is the name of the current insurance carrier for this property? Home 1
What is the name of the current insurance carrier for this property?
New Purchase Occupancy home 1
Please select the intended occupancy of the property you are purchasing.
- Primary residence
- Secondary residence
- Rented to others (long-term or seasonal tenants)
- Short-term Rentals (I.e. AirBNB, VRBO, etc.)
- Unoccupied
- Vacant (No contents)
- Under construction/renovation
- Other
New Purchase Occupancy Other home 1
What is the intended occupancy of the home you are purchasing?
Owned Home Occupancy home 1
Please select the occupancy of this home.
- Primary residence
- Secondary residence
- Rented to others (long-term or seasonal tenants)
- Short-term Rentals (I.e. AirBNB, VRBO, etc.)
- Unoccupied
- Vacant (No contents remain)
- Under construction/renovation
- Other
Owned Home Occupancy Other home 1
What is the intended occupancy of the home you are purchasing?
Current Home Address home 1
Please enter your current home address.

Street Address Address Line 2 City State ZIP Code
Primary Home Address home 1
Please enter your primary home address.

Street Address Address Line 2 City State ZIP Code
Have you lived at your current address for three or more years? * home 1
Have you lived at your current address for three or more years? *
- Yes
- No
Have you lived at your primary home address for three or more years? * home 1*
Have you lived at your primary home address for three or more years? *
- Yes
- No
New Purchase - Previous Home Address home 1
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Owned Home - Previous Home Address home 1
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Will you occupy one of the units in this multi-family home? home 1
Will you occupy one of the units in this multi-family home?
- Yes
- No
Will all units be occupied at or shortly after closing? home 1
Will all units be occupied at or shortly after closing?
- Yes
- No
Do you have any construction or renovations planned to start shortly after closing? * home 1*
Do you have any construction or renovations planned to start shortly after closing? *
- Yes
- No
Renovation Budget home 1
What is the approximate budget for the construction/renovation?
Will the home be occupied during the construction/renovation? * home 1*
Will the home be occupied during the construction/renovation? *
- Yes
- No
- Not sure
Will the home be unoccupied more than 30 days? * home 1*
Will the home be unoccupied more than 30 days? *
- Yes
- No
- Not sure
Please provide a brief description of the renovation. home 1
Please provide a brief description of the renovation.
Have any renovations been done previously? * home 1*
Have any renovations been done previously? *
- Yes
- No
- Not sure
What year was the most recent or largest renovation completed? * home 1*
What year was the most recent or largest renovation completed? *
Please provide some details about the previous renovation(s). (I.e. Partially finished basement, wine cellar, garage, added a bath, etc.) home 1
Please provide some details about the previous renovation(s). (I.e. Partially finished basement, wine cellar, garage, added a bath, etc.)
Please select the frequency of rentals for this home. home 1
Please select the frequency of rentals for this home.
- 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? * home 1*
Will there be a mortgage? *
- Yes
- No
What is the name of the bank providing the mortgage? home 1
What is the name of the bank providing the mortgage?
Who is your contact at the bank? home 1
Who is your contact at the bank?
What is the phone number for your contact at the bank? home 1
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank? home 1
What is the email address for your contact at the bank?
Is there a mortgage? home 1
Is there a mortgage?
- Yes
- No
Please enter the bank name, if convenient. home 1
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. home 1
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. home 1
Please enter the loan number, if convenient.
Trust or LLC home 1*
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property? *
- Yes
- No
Trust or LLC Name home 1*
Please enter the name of the Trust, LLC or Limited Partnership: *
Trust or LLC Purpose home 1*
What is the purpose of the legal entity? (I.e. Estate planning, privacy, asset protection, business, etc.) *
Alarm System * home 1*
Is there an alarm system in this home that is monitored by a third party? *
- Yes
- No
Are you willing/planning to install an alarm system? * home 1*
Are you willing/planning to install an alarm system? *
- Yes
- No
- Not sure
Alarm System Components home 1
Select the components of your monitored alarm system.
- Heat/Smoke detectors
- Burglar motion sensors
- Low temperature monitor
- Water leak detection
- 24-hour signal continuity
- 24-hour video surveillance
- Gas leak detection
Please select the protection features of this property. home 1
Please select the protection features of this property.
- Permanently installed back-up generator (Automatic start)
- Indoor sprinkler system
- Automatic water shut-off valve
- Lightning protection system (Fire suppression)
- Gated house
- Gated community
- 24 Hour guard gated community
- Fenced in property
- In home safe/vault (secured to ground)
- Flood vents
- Seismic shut-off valve
- LEED Certified
- None
- Other
Risk Mitigation Other home 1
Enter the other protection feature(s) in this home.
Approximate Square Footage * home 1
What is the approximate square footage of the living area of this home? *
What year was this home built? (YYYY) * home 1*
What year was this home built? (YYYY) *
How many stories does this home have, including a basement? home 1
How many stories does this home have, including a basement?
What is the age of the roof or year of last update? (YYYY) * home 1
What is the age of the roof or year of last update? (YYYY) *
Please select your roof material. * home 1*
Please select your roof material. *
- Asphalt Shingle
- Architectural Shingle
- Wood Shingle
- Metal Roof
- Rubber Roof
- Cement Tile
- Clay Tile
- Other
- Not sure
Please provide a brief description of your roof material. home 1
Please provide a brief description of your roof material.
Please select the construction type of your home. * home 1*
Please select the construction type of your home. *
- Wood Frame
- Brick/Concrete
- Masonry
- Post & Beam
- Joisted Masonry
- Stucco on Frame
- Steel
- Other
- Not Sure
Please provide a brief description of the construction type of your home. home 1
Please provide a brief description of the construction type of your home.
Please select the features of your home that have been updated within the last 25 years. * home 1*
Please select the features of your home that have been updated within the last 25 years. *
- Electrical
- Plumbing
- Heating
- Windows
- None
- Other
What other updates have you done to your home? home 1
What other updates have you done to your home?
What year did you update the electrical? (YYYY) * home 1*
What year did you update the electrical? (YYYY) *
What year did you update the plumbing? (YYYY) * home 1*
What year did you update the plumbing? (YYYY) *
What year did you update the heating? (YYYY) * home 1*
What year did you update the heating? (YYYY) *
What year did you update the windows? (YYYY) home 1
What year did you update the windows? (YYYY)
What type of foundation/basement does this home have? * home 1*
What type of foundation/basement does this home have? *
- Finished Basement Below Grade
- Finished Basement Walk Out
- Partially Finished Below Grade
- Partially Finished Walk Out
- Unfinished Basement Below Grade
- Unfinished Basement Walk Out
- Crawlspace
- Slab
- Stilts
Please describe your partially/fully finished basement. home 1
Please describe your partially/fully finished basement. (I.e. Wine cellar, theater, recreational room, etc.)
Are there any detached structures on the property? * home 1*
Are there any detached structures on the property? *
- Yes
- No
Please select the detached structures on this property. * home 1*
Please select the detached structures on this property. *
- Pool
- Pool house
- Fence
- Rock Wall
- Detached garage
- Cabana
- Green house
- Guest house
- Tree house
- She shed
- Jungle gym
- Dock
- Stone walls
- Barn
- Shed
- Tennis court
- Other
Other Property Structures home 1
Enter a brief description of the other structure(s) on this property.
What features apply to the pool? * (Select all that apply) home 1*
What features apply to the pool? * (Select all that apply)
- Fenced
- Diving Board
- Slide
- Hot Tub
- Pool enclosure
- None
How many car bays does the detached garage have? * home 1*
How many car bays does the detached garage have? *
Is there an attached garage? * home 1*
Is there an attached garage? *
- Yes
- No
How many car bays does the attached garage have? * home 1*
How many car bays does the attached garage have? *
Is this a condominium or cooperative? * Condo/Coop 1*
Is this a condominium or cooperative? *
- Condominium
- Cooperative
Are you in the process of purchasing this condominium/cooperative? * Condo/Coop 1*
Are you in the process of purchasing this condominium/cooperative? *
- Yes
- No
Purchase Price? Condo/Coop 1
What is the purchase price?
New Condo / Coop Closing Date? Condo/Coop 1
What is the closing date?
MM slash DD slash YYYY
Current Insurer Condo/Coop 1
What is the name of your current insurance company?
Desired Effective Date? Condo/Coop 1
When would you like coverage to start?
MM slash DD slash YYYY
New Purchase Occupancy Condo/Coop 1
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 Condo/Coop 1
Please describe the intended occupancy of the home you are purchasing.
Owned Condo/Coop Occupancy Condo/Coop 1
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 Condo/Coop Occupancy other Condo/Coop 1
What is the occupancy of this condominium/cooperative?
Primary Home Address Condo/Coop 1
What is your primary home address?

Street Address Address Line 2 City State ZIP Code
New Purchase - 3 Yrs at Current Residence Condo/Coop 1
Have you lived at your current address for three or more years?
- Yes
- No
Owned Home - 3 Yrs at Current Residence Condo/Coop 1
Have you lived at your primary home address for three or more years?
- Yes
- No
New Purchase - Previous Home Address Condo/Coop 1
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Owned Home - Previous Home Address Condo/Coop 1
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Major Renovation Condo/Coop 1*
Will you renovate this condo/co-op before moving in? *
- Yes
- No
Renovation Budget? Condo/Coop 1
What is the renovation budget?
Renovation Time Frame Condo/Coop 1
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
Renovation Description Condo/Coop 1
Please provide a brief description of your renovation plans.
Condo/Coop Rental Frequency Condo/Coop 1
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...
New Purchase Mortgage? Condo/Coop 1*
Will there be a mortgage? *
- Yes
- No
Bank/Lender Name? Condo/Coop 1
What is the name of the bank providing the mortgage?
New Purchase Bank Contact? Condo/Coop 1
Who is your contact at the bank?
New Purchase Bank Phone? Condo/Coop 1
What is the phone number for your contact at the bank?
New Purchase Bank Email? Condo/Coop 1
What is the email address for your contact at the bank?
Existing Condo/Coop Mortgage? Condo/Coop 1*
Is there a mortgage? *
- Yes
- No
Please enter the bank name, if convenient. Condo/Coop 1
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. Condo/Coop 1
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. Condo/Coop 1
Please enter the loan number, if convenient.
Trust or LLC Condo/Coop 1
Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?
- Yes
- No
Legal Entity Name *. Condo/Coop 1
What is the name of the legal entity? *
Legal Entity Purpose *. Condo/Coop 1*
What is the purpose of the legal entity? (I.e. Estate planning, privacy, asset protection, business, etc.) *
Alarm System Condo/Coop 1
Does this condo/co-op have an active monitored alarm system?
- Yes
- No
Alarm System Components Condo/Coop 1
Select the components of your alarm system.
- Monitored Fire Alarm in the Unit
- Monitored Burglar Alarm in the Unit
- 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 Condo/Coop 1
What other components do you have in your alarm system?
Unit Fire Sprinklers? Condo/Coop 1
Does this unit have fire suppression sprinklers?
- Yes
- No
- Not sure
What year was this condo/co-op built? Condo/Coop 1*
What year was this condo/co-op built? *
What is the square footage of this unit? * Condo/Coop 1*
What is the square footage of this unit? *
How many stories does the building have? * Condo/Coop 1*
How many stories does the building have? *
On which floor is the unit located? * Condo/Coop 1*
On which floor is the unit located? *
System/features Updates Condo/Coop 1*
Select the elements of this condo/co-op that have been updated. *
- Electrical
- Plumbing
- Heating
- Windows
- None
- Other
System/features updates other Condo/Coop 1
What other updates have been done to your home?
Electrical update year Condo/Coop 1*
What year was the electrical updated? *
Plumbing update year Condo/Coop 1*
What year was the plumbing updated? *
Heating system update year Condo/Coop 1*
What year was the heating system updated? *
Windows update year Condo/Coop 1
What year were the windows updated?
Roof Age Condo/Coop 1
What is the age of the building's roof?
Roof Type Condo/Coop 1
What type of roof does this building have?
- Asphalt Shingle
- Architectural Shingle
- Wood Shingle
- Metal Roof
- Tar and Gravel
- Rubber Roof
- Cement Tile
- Clay Tile
- Other
Roof Type Other Condo/Coop 1
Please provide a description of this building's roof type.
Previous Renovations? Condo/Coop 1*
Do you know of any previous renovations done to this unit? *
- Yes
- No
Previous Renovation Information Condo/Coop 1
Please share the information you have about any previous renovations in this unit.
Personal Property Limit - Condo/Coop * Condo/Coop 1*
What would it cost to replace your personal belongings/contents at this location? (I.e. Clothing, furniture, rugs, electronics, etc...) *
Renters effective date. Renters 1*
When would you like this insurance to start? *
MM slash DD slash YYYY
Occupancy Renters 1
Please select the occupancy of this property.
- Primary residence
- Secondary residence
- Other
Please describe the occupancy of the property. Renters 1
Please describe the occupancy of the property.
Renters Address Renters 1*
Please enter the address for this location. (Include apartment number, if applicable)

Street Address Address Line 2 City State ZIP Code
Alarm System Renters 1
Is there an active monitored alarm system in this residence?
- Yes
- No
Alarm System Components Renters 1
Select the components of your alarm system.
- Heat/Smoke detectors
- Burglar motion sensors
- Low temperature monitor
- Water leak detection
- Water flow alarm
- 24-hour signal continuity
- 24-hour video surveillance
- Gas leak detection
Renters Personal Property Limit Renters 1*
What is the approximate value of the personal belongings you will have at this residence? (Personal belongings include furniture, clothing, electronics, kitchen items, linens, and other possessions that you own.) *
Approximate Square Footage Renters 1
What is the approximate square footage of this property?
Year Built Renters 1
What year was this residence built? (YYYY)
Construction Renters 1
What was the primary construction material used to build this residence?
Property Structures Renters 1
Please select the other structures at this residence.
- Pool
- Pool house
- Fence
- Detached garage
- Guest house
- Jungle gym
- Dock
- Stone walls
- Barn
- Shed
- Tennis court
- Other
- None
Additional Coverages - Location 1
Are you interested in including any of the following additional coverages in this analysis? * (Select all that apply)
- Buried Utility Lines
- Earthquake
- Equipment Breakdown
- Mold & Fungi
- Not interested
Has your home been structurally retrofitted or reinforced to better withstand earthquakes? **
Has your home been structurally retrofitted or reinforced to better withstand earthquakes? *
- Yes
- No
Would you like to include flood insurance to help protect your home against water damage caused by heavy rain or other ground-level flooding? **
Would you like to include flood insurance to help protect your home against water damage caused by heavy rain or other ground-level flooding? *
- Yes
- No
Flood Insurance - Location 1

Do you have an elevation certificate? * Flood 1*
Do you have an elevation certificate? *
- Yes
- No
Please upload an elevation certificate for this home, if one is available. Flood 1
Please upload an elevation certificate for this home, if one is available.
Max. file size: 128 MB.
Is the home built over water? * Flood 1*
Is the home built over water? *
- Yes
- No
What is the approximate distance to the nearest shoreline? * Flood 1*
What is the approximate distance to the nearest shoreline? *
Has this home had any prior flood losses? * Flood 1*
Has this home had any prior flood losses? *
- Yes
- No
Please enter the date, description, and amount of the flood loss. * Flood 1*
Please enter the date, description, and amount of the flood loss. *
Date of Loss Description Amount
Is there machinery that services this residence in the basement? (I.e. Central air conditioner, furnace, hot water heater, heat pump, elevator machinery and equipment.) **
Is there machinery that services this residence in the basement? (I.e. Central air conditioner, furnace, hot water heater, heat pump, elevator machinery and equipment.) *
- Yes
- No
What is the approximate value of the machinery that services the building? * Flood 1*
What is the approximate value of the machinery that services the building? *
- $1,000 - $10,000
- $10,000 - $20,000
- Over $20,000
Are there any washers/dryers/food freezers located in the basement? * Flood 1*
Are there any washers/dryers/food freezers located in the basement? *
- Yes
- No
What is the approximate value of the washers/dryers/food freezers located in the basement? * Flood 1*
What is the approximate value of the washers/dryers/food freezers located in the basement? *
- $1,000 - $5,000
- $5,000 - $10,000
- Over $10,000
Does this home have flood vents? Flood 1
Does this home have flood vents?
- Yes
- No
Do you have a flood insurance policy in place today? Flood 1
Do you have a flood insurance policy in place today?
- Yes
- No
Please upload a copy of your Flood insurance policy, if available. Flood 1
Please upload a copy of your Flood insurance policy, if available.
Accepted file types: pdf, jpeg, jpg, png, Max. file size: 10 MB.
Have there been any claims at this location in the past 5 years? * Location 1
Have there been any claims at this location in the past 5 years? *
- Yes
- No
Please provide the requested details for the claim(s) below. * Location 1*
Please provide the requested details for the claim(s) below. *
Date Description Amount Paid
Special Features Home Location 1 home 1
Please tell us about any other special features in your home: (I.e. Home theater, wine cellar, indoor spa, wet bars, ornate moldings, cathedral ceilings, etc.)
Location 1 - Wind Coverage

Has a 4-point inspection been done for this property? Wind 1
Has a 4-point inspection been done for this property?
- Yes
- No
Please upload a copy of the 4-point inspection, if available. Wind 1
Please upload a copy of the 4-point inspection, if available.
Max. file size: 128 MB.
Has a windstorm/wind mitigation inspection been done for this property? * Wind 1*
Has a windstorm/wind mitigation inspection been done for this property? *
- Yes
- No
Please upload a copy of the windstorm/wind mitigation certificate, if available. Wind 1
Please upload a copy of the windstorm/wind mitigation certificate, if available.
Max. file size: 128 MB.
Location 1 - Wildfire Risk Questions

Is there a combustible deck or attached structure at this home? wildfire 1
Is there a combustible deck or attached structure at this home?
- Yes
- No
Do you have a permanently installed wildfire suppression system at this home? wildfire 1
Do you have a permanently installed wildfire suppression system at this home?
- Yes
- No
Brush clearance 100 Feet wildfire 1
Is there at least 100 feet of brush clearance surrounding the residence? (Brush vegetation is a general term for woody plants, such as shrubs and small trees, that grow thickly together.)
- Yes
- No
What is the distance to the nearest fire hydrant? (In feet) wildfire 1
What is the distance to the nearest fire hydrant? (In feet)
Is there any wood mulch within 5 feet of the home? wildfire 1
Is there any wood mulch within 5 feet of the home?
- Yes
- No
Are there any trees within 10 feet of any structure? (I.e. Pine, Pinion, Juniper, etc.) wildfire 1
Are there any trees within 10 feet of any structure? (I.e. Pine, Pinion, Juniper, etc.)
- Yes
- No
Are there any tree branches overhanging any structure? wildfire 1
Are there any tree branches overhanging any structure?
- Yes
- No
Are there any alternative water sources on properties such as tanks or pools? wildfire 1
Are there any alternative water sources on properties such as tanks or pools?
- Yes
- No
Please provide a description of the alternative water source(s) and how many gallons it holds. wildfire 1
Please provide a description of the alternative water source(s) and how many gallons it holds.
Are eave soffits and attic vents fitted with narrow mesh screens? wildfire 1
Are eave soffits and attic vents fitted with narrow mesh screens?
- Yes
- No
Are chimneys fitted with spark arrestors? wildfire 1
Are chimneys fitted with spark arrestors?
- Yes
- No
Is firewood or other combustible materials stored at least 30 feet from the home? wildfire 1
Is firewood or other combustible materials stored at least 30 feet from the home?
- Yes
- No
Are combustible structures or fuel tanks at least 30 feet from the home and have at least 10 feet around clear of combustible materials? wildfire 1
Are combustible structures or fuel tanks at least 30 feet from the home and have at least 10 feet around clear of combustible materials?
- Yes
- No
Please describe any additional mitigation efforts or devices, such as dry hydrants, pumps, annual fire-retardant treatments, gutter guards, bird stops, or other protective measures. wildfire 1
Please describe any additional mitigation efforts or devices, such as dry hydrants, pumps, annual fire-retardant treatments, gutter guards, bird stops, or other protective measures.
(ADVISOR USE) - Location 1 Coverage Limits

Dwelling/Additions & Alterations Location 1
Dwelling/Additions & Alterations
Other Structures (N/A for condos, coops, and renters) Location 1
Other Structures (N/A for condos, coops, and renters)
Personal Property/Contents Location 1
Personal Property/Contents
Loss of Use/Additional Living Expenses Location 1
Loss of Use/Additional Living Expenses
Personal Liability Location 1
Personal Liability
Medical Payments Location 1
Medical Payments
Regular or All Other Perils Deductible Location 1
Regular or All Other Perils Deductible
Hurricane/Named Storm/Wind Deductible (What type and %) Location 1
Hurricane/Named Storm/Wind Deductible (What type and %)
Water/Sewer Backup Location 1
Water/Sewer Backup
Flood/Surface Water Location 1
Flood/Surface Water
Earthquake Location 1
Earthquake
Equipment Breakdown/Systems Location 1
Equipment Breakdown/Systems
Mold or Fungi Remediation Amount Location 1
Mold or Fungi Remediation Amount
Cyber Liability Location 1
Cyber Liability
Other (I.e. Sink hole) Location 1
Other (I.e. Sink hole)
Enter any quoting instructions/notes below. Location 1
Enter any quoting instructions/notes below.
Location 2
Location 3
Location 4
New Construction/Renovation (Home/Condominium/Cooperative)
What is the address/lot number where the construction/renovation will take place? **
What is the address/lot number where the construction/renovation will take place? *

Street Address Address Line 2 City State ZIP Code
Do you have insurance for this property currently?
Do you have insurance for this property currently?
- Yes
- No
What is the name of the insurance company?
What is the name of the insurance company?
Are you planning to purchase this property?
Are you planning to purchase this property?
- Yes
- No. The property is already owned.
What is the closing date? 1
What is the closing date?
MM slash DD slash YYYY
What is the purchase price?
What is the purchase price?
General Project Information
Is this a new construction or a renovation project? **
Is this a new construction or a renovation project? *
- New Construction
- Renovation
Please select the type(s) of structure(s) you will be constructing.*
Please select the type(s) of structure(s) you will be constructing. (Select all that apply) *
- New House
- Guest House
- Detached Garage
- Barn
- Pool
- Pool House
- Pool Enclosure
- Other
What year was the home built? **
What year was the home built? *
What is the total estimated cost of construction for your new house? **
What is the total estimated cost of construction for your new house? *
Please enter a number greater than or equal to 0.
What will the square footage of your new house be? **
What will the square footage of your new house be? *
Please enter a number greater than or equal to 0.
What type of construction will this new house be? *
What type of construction will this new house be? *
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
How many stories will your new house have?
How many stories will your new house have?
Please describe the other structure(s) you will be constructing.
Please describe the other structure(s) you will be constructing.
What is the total estimated cost of construction for the guest house?
What is the total estimated cost of construction for the guest house?
Please enter a number greater than or equal to 0.
What will the square footage of your guest house be?
What will the square footage of your guest house be?
Please enter a number greater than or equal to 0.
How many stories will your guest house have?
How many stories will your guest house have?
Please enter a number greater than or equal to 0.
What type of construction will this guest house be?
What type of construction will this guest house be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the detached garage?
What is the total estimated cost of construction for the detached garage?
Please enter a number greater than or equal to 0.
What will the square footage of the detached garage be?
What will the square footage of the detached garage be?
Please enter a number greater than or equal to 0.
How many stories will the detached garage have?
How many stories will the detached garage have?
Please enter a number greater than or equal to 0.
What type of construction will this detached garage be?
What type of construction will this detached garage be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the barn?
What is the total estimated cost of construction for the barn?
Please enter a number greater than or equal to 0.
What will the square footage of the barn be?
What will the square footage of the barn be?
Please enter a number greater than or equal to 0.
How many stories will the barn have?
How many stories will the barn have?
Please enter a number greater than or equal to 0.
What type of construction will this barn be?
What type of construction will this barn be?
- Frame
- Masonry
- Masonry veneer
- Non-Combustible
- Fire Resistive (No wood in structure)
- Brick
- Stucco over frame
What is the total estimated cost of construction for the pool?
What is the total estimated cost of construction for the pool?
Please enter a number greater than or equal to 0.
What is the total estimated cost of construction for the pool house?
What is the total estimated cost of construction for the pool house?
Please enter a number greater than or equal to 0.
What is the total estimated cost of construction for the pool enclosure?
What is the total estimated cost of construction for the pool enclosure?
Please enter a number greater than or equal to 0.
What is the total estimated cost of construction for the other structure(s)?
What is the total estimated cost of construction for the other structure(s)?
Please enter a number greater than or equal to 0.
What is the expected total cost of this new construction project? (Labor and materials, contractor profit and overhead, architect fees, interior designer fees, engineering or other speciality contractor fees, cost of cut, fill or backfill for site work, landscaping to be installed including plants and trees.) **
What is the expected total cost of this new construction project? (Labor and materials, contractor profit and overhead, architect fees, interior designer fees, engineering or other speciality contractor fees, cost of cut, fill or backfill for site work, landscaping to be installed including plants and trees.) *
Please enter a number greater than or equal to 0.
Please select the areas that will be included in your renovation. **
Please select the areas that will be included in your renovation. (Select all that apply) *
- Kitchen
- Bathroom(s)
- Moving load bearing walls
- Refinishing hardwood floors
- Deck
- Patio
- Painting
- Adding an addition
- Finishing the basement
- Roof
- Other
Please describe the other areas that will be part of this renovation.
Please describe the other areas that will be part of this renovation.
What is the square footage of the residence before the project begins?
What is the square footage of the residence before the project begins?
How much square footage is being added with this addition?
How much square footage is being added with this addition?
Please enter a number greater than or equal to 0.
What is the budget for this renovation project?
What is the budget for this renovation project?
Please enter a number greater than or equal to 0.
Will you continue to occupy the residence during the renovation?
Will you continue to occupy the residence during the renovation?
- Yes
- No
- Not sure
What is the address where you will live during the renovation?
What is the address where you will live during the renovation?

Street Address Address Line 2 City State ZIP Code
How long do you plan to be out of your home? **
How long do you plan to be out of your home? *
Will any of your personal property be stored at this residence during the renovation? **
Will any of your personal property be stored at this residence during the renovation? *
- Yes
- No
What is the approximate value of the personal property that will be stored at this residence during the renovation? **
What is the approximate value of the personal property that will be stored at this residence during the renovation? *
Please enter a number greater than or equal to 0.
Will any structure(s) be demolished as part of this project? **
Will any structure(s) be demolished as part of this project? *
- Yes
- No
- Not sure
Please provide a brief description of the demolition work and the structure(s) being demolished. *
Please provide a brief description of the demolition work and the structure(s) being demolished. *
Please provide a general description and/or additional information about the work to be done below. **
Please provide a general description and/or additional information about the work to be done below. *
Are you concerned about damage caused by surface water or flooding? **
Are you concerned about damage caused by surface water or flooding? *
- Yes
- No
Does the seller have a flood policy in place? **
Does the seller have a flood policy in place? *
- Yes
- No
- Not sure
Do you have an elevation certificate for this property? **
Do you have an elevation certificate for this property? *
- Yes
- No
Are you concerned about damage caused by earthquake? **
Are you concerned about damage caused by earthquake? *
- Yes
- No
Would you interested in having mold remediation coverage, if the residence were damaged by water? **
Would you interested in having mold remediation coverage, if the residence were damaged by water? *
- Yes
- No
Will any building materials be stored onsite? *
Will any building materials be stored onsite? *
- Yes
- No
- Not sure
Will any building materials be stored offsite? *
Will any building materials be stored offsite? *
- Yes
- No
- Not sure
Project Schedule
Has construction already started? **
Has construction already started? *
- Yes
- No
What percentage of the work is complete? **
What percentage of the work is complete? *
Please explain why coverage is being requested at this time. **
Please explain why coverage is being requested at this time. *
Has there been any coverage up to this point? **
Has there been any coverage up to this point? *
- Yes
- No
What insurance company is currently covering this project? **
What insurance company is currently covering this project? *
How many days a week is the builder working at this site? **
How many days a week is the builder working at this site? *
What date will this project begin? **
What date will this project begin? *
MM slash DD slash YYYY
What date will the new construction be fully enclosed and the electrical roughed in? **
What date will the new construction be fully enclosed and the electrical roughed in? *
MM slash DD slash YYYY
What date will this project be completed? **
What date will this project be completed? *
MM slash DD slash YYYY
Do you intend to occupy the residence upon project completion? **
Do you intend to occupy the residence upon project completion? *
- Yes, this will be my primary residence
- Yes, this will be a secondary residence
- No, someone else will occupy it
- No, it will be vacant
Who will occupy this home upon completion?
Who will occupy this home upon completion?
Will you furnish this residence directly after completion of the construction/renovation or will it be vacant for a period of time? **
Will you furnish this residence directly after completion of the construction/renovation or will it be vacant for a period of time? *
Interested Parties
Will there be a mortgage for this project? **
Will there be a mortgage for this project? *
- Yes
- No
- Not sure
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?
Will the insurance premium be escrowed?
Will the insurance premium be escrowed?
- Yes
- No
- Not sure
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.
Is the insurance premium being escrowed?
Is the insurance premium being escrowed?
- Yes
- No
- Not sure
Trust or LLC construction 1 **
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property? *
- Yes
- No
Trust or LLC Name * COC/COR 1*
Please enter the name of the Trust, LLC or Limited Partnership: *
What is the purpose or intent of the entity? COC/COR 1 **
What is the purpose or intent of the entity? (I.e. Estate planning, privacy, asset protection, business, etc.) *
General Contractor
Have you selected a general contractor for this project?
Have you selected a general contractor for this project?
- Yes
- Not yet
- I will be the general contractor
Will you hire subcontractors for any of the work?
Will you hire subcontractors for any of the work?
- Yes
- No
What date will you select your general contractor?
What date will you select your general contractor?
MM slash DD slash YYYY
General Contractor Information
What is the name of the general contractor's business?
What is the name of the general contractor's business?
Please enter the general contractor's website address.
Please enter the general contractor's website address.
Please enter the site foreman/project manager's name.
Please enter the site foreman/project manager's name.
Please enter the site foreman/project manager's phone number.
Please enter the site foreman/project manager's phone number.
Please enter the site foreman/project manager's email address.
Please enter the site foreman/project manager's email address.
How many years has the general contractor's company been in business?
How many years has the general contractor's company been in business?
Please enter a number greater than or equal to 0.
How many projects does the GC typically start and complete in one year?
How many projects does the GC typically start and complete in one year?
How many projects does the GC have underway currently?
How many projects does the GC have underway currently?
Do you have a certificate of insurance from the general contractor listing you as an additional insured and certificate holder?
Do you have a certificate of insurance from the general contractor listing you as an additional insured and certificate holder?
- Yes
- No
Does the general contractor have a builders risk policy in effect for this project?
Does the general contractor have a builders risk policy in effect for this project?
- Yes
- No
- Not sure
Will the general contractor be hiring subcontractors?
Will the general contractor be hiring subcontractors?
- Yes
- No
- Not sure
Does the GC require all subcontractors to carry Commercial General Liability (CGL) and Workers Compensation Insurance?
Does the GC require all subcontractors to carry Commercial General Liability (CGL) and Workers Compensation Insurance?
- Yes
- No
Do you have a contract with the general contractor?
Do you have a contract with the general contractor?
- Yes
- No
- Not sure
Does your contract include a waiver of subrogation?*
Does your contract include a waiver of subrogation? (A waiver of subrogation is an agreement that prevents an insurance company from pursuing recovery from a third party responsible for a loss.)
- Yes
- No
- Not sure
Have you signed a waiver of subrogation with your contractor?*
Have you signed a waiver of subrogation with your contractor? (A waiver of subrogation is an agreement that prevents an insurance company from pursuing recovery from a third party responsible for a loss.)
- Yes
- No
- Not sure
Please enter a description of the 5 most recent projects the general contractor has completed and their total square footage. (Skip this if the information is not available at this time)
Please enter a description of the 5 most recent projects the general contractor has completed and their total square footage. (Skip this if the information is not available at this time)
Project Description Square Foot Value of Work ($)
Have any of the projects the GC worked on in the past 5 years suffered a property loss or claim?
Have any of the projects the GC worked on in the past 5 years suffered a property loss or claim?
- Yes
- No
Please provide the approximate date and a description of the claim(s) or lawsuit(s) below. **
Please provide the approximate date and a description of the claim(s) or lawsuit(s) below. *
Date Description
Risk Management on Site
Will an active central station burglar and fire alarm system be in place once the structure is enclosed? **
Will an active central station burglar and fire alarm system be in place once the structure is enclosed? *
- Yes
- No
Please select all risk management strategies that will be employed during the project.
Please select all risk management strategies that will be employed during the project.
- Fire extinguisher(s)
- No smoking sign(s)
- Fire proof storage cabinet for flammable liquids
- No trespassing sign(s)
- Driveway chain
- Temporary/permanent central station fire alarm
- Temporary/permanent central station burglar alarm
- Full perimeter security fencing
- Motion activated security lighting
- Automatic water shutoff valve
- Guard gated community
- Security guard or watchmen
- Monitored exterior video surveillance system
- Contractor signage
- Disconnect all extension cords and remove debris daily
- Residential fire sprinkler water flow alarms
- Hot works program
- Vibration sensors
- Other
Provide a brief description of the other risk management strategies that will be employed.
Provide a brief description of the other risk management strategies that will be employed.
Valuable Articles
Do you have coverage in place for your valuable collections?
Do you have coverage in place for your valuable collections?
- Yes
- No
What is the name of the current insurance carrier?
What is the name of the current insurance carrier?
Valuables Categories
Please select the types of valuable articles you would like to include in this coverage analysis?
- Jewelry
- Fine Art
- Wine
- Firearms
- Musical Instruments
- Silverware
- Furs
- Other/Collectibles
Jewelry Collection
Tell us about your jewelry collection.
How many pieces Total collection value Value of most significant piece
Do you store any of your jewelry items in a bank vault?
Do you store any of your jewelry items in a bank vault?
- Yes
- No
What is the value of the jewelry stored in the bank vault?
What is the value of the jewelry stored in the bank vault?
Do you have a safe permanently installed in your residence to store your jewelry in?
Do you have a safe permanently installed in your residence to store your jewelry in?
- Yes
- No
Jewelry Appraisals?
Do you have any recent appraisals for your jewelry? (3 years old or newer)
- Yes
- No
Jewelry Appraisal Upload
Feel free to upload your appraisals here.
Drop files here or

Max. file size: 128 MB.
Fine Art Collection
Tell us about your fine art collection.
How many pieces Total collection value Value of most significant piece
Fine Art Appraisals?
Do you have any recent appraisals for your fine art? (5 years old or newer)
- Yes
- No
Fine Art Appraisal Upload
Feel free to upload your appraisals here.
Drop files here or

Max. file size: 128 MB.
Wine Collection
Tell us about your wine collection.
How many pieces Total collection value Value of most significant piece
Firearms Collection
Tell us about your firearms collection.
How many pieces Total collection value Value of most significant piece
Musical Instruments Collection
Tell us about your musical instruments collection.
How many pieces Total collection value Value of most significant piece
Silverware
Tell us about your silverware collection.
How many pieces Total collection value Value of most significant piece
Furs
Tell us about your fur collection.
How many furs Total collection value Value of most significant fur
Other Collection
Tell us about your other collections.
Description How many pieces Total collection value Value of most significant
Have you had any valuable collections claims or losses in the last 5 years? **
Have you had any valuable collections claims or losses in the last 5 years? *
- Yes
- No
Please enter the requested details about any claims or losses from the last 5 years. **
Please enter the requested details about any claims or losses from the last 5 years. *
Date Description Amount Paid
Valuable collection notes
Please enter any additional comments about your valuable collections below.
Valuable Articles (ADVISOR USE) - QUOTING INSTRUCTIONS
Please enter the coverage limits to quote for jewelry.
Please enter the coverage limits to quote for jewelry.
Blanket Jewelry Total Blanket Per Item Cap Itemized Jewelry Total
Please enter the coverage limits to quote for fine art.
Please enter the coverage limits to quote for fine art.
Blanket Fine Art Total Blanket Per Item Cap Itemized Fine Art Total
Please enter the coverage limits to quote for wine.
Please enter the coverage limits to quote for wine.
Blanket Wine Total Blanket Per Item Cap Itemized Wine Total
Please enter the coverage limits to quote for firearms.
Please enter the coverage limits to quote for firearms.
Blanket Firearms Total Blanket Per Item Cap Itemized Firearms Total
Please enter the coverage limits to quote for musical instruments.
Please enter the coverage limits to quote for musical instruments.
Blanket Musical Instruments Total Blanket Per Item Cap Itemized Musical Instruments Total
Please enter the coverage limits to quote for silverware.
Please enter the coverage limits to quote for silverware.
Blanket Silverware Total Blanket Per Item Cap Itemized Silverware Total
Please enter the coverage limits to quote for furs.
Please enter the coverage limits to quote for furs.
Blanket Furs Total Blanket Per Item Cap Itemized Furs Total
Please enter the coverage limits to quote for other/collectibles.
Please enter the coverage limits to quote for other/collectibles.
Blanket Furs Total Blanket Per Item Cap Itemized Furs Total
Please enter any specific quoting instructions for valuable articles coverage below.
Please enter any specific quoting instructions for valuable articles coverage below.
Automobile
Do you currently have auto insurance? **
Do you currently have auto insurance? *
- Yes
- No
What is the name of your current auto insurance company?
What is the name of your current auto insurance company?
How many accidents, claims and/or motor vehicle violations have there been in your household in the last five years? *
How many accidents, claims and/or motor vehicle violations have there been in your household in the last five years? *
Please enter a number from 0 to 10.
Please enter the details requested for all accidents, claims and/or motor vehicle violations below.
Please enter the details requested for all accidents, claims and/or motor vehicle violations below.
Date Description Amount Paid
What date do you want this coverage in place? **
What date do you want this coverage in place? *
MM slash DD slash YYYY
Vehicle Information
How many vehicles do you have? *
How many vehicles do you have? (Enter a number) *
Please enter a number from 1 to 20.
Please enter the Year, Make, Model and Vin (17 digits) for each vehicle. **
Please enter the Year, Make, Model and Vin (17 digits) for each vehicle. *
Vehicle )Year, Make, Model) Vehicle Identification Number (VIN) Registration State Garaging City
Enter the following requested information for each principal, partner, director or officer.
Enter the following requested information for each vehicle.
Vehicle (Year, Make, Model) Annual Mileage $ Values Ownership (Leased, Financed, Owned)
Entity Ownership
Any of your vehicles owned by a Business, Trust, LLC or Limited Partnership?
- Yes
- No
Ownership Details
Please provides details about vehicle ownership.
Vehicle (Year, Make, Model) Vehicle Owner Name
Driver Information
Driver information **
How many drivers are there in the household? *
Please enter a number from 1 to 10.
Drivers Information
Please enter the requested information for all drivers in the household.
First and Last Name Date of birth License state License number Gender
Additional driver information
Please enter the requested information for all drivers in the household.
First and Last Name Primary Car? Usage (Pleasure, Commuting, Business) Driver Training Certificate? Good Student/B or better? Defensive Driving Course? Away at School? School Name?
Automobile (ADVISOR USE) - QUOTING INSTRUCTIONS
Bodily injury liability (Auto)
Bodily injury liability
Property damage liability (Auto)
Property damage liability
Uninsured/underinsured motorist (Auto)
Uninsured/underinsured motorist
Uninsured/underinsured property damage (Select states) (Auto)
Uninsured/underinsured property damage (Select states)
Personal injury protection (Select states) (Auto)
Personal injury protection (Select states)
Lawsuit option (Select states) (Auto)
Lawsuit option (Select states)
Medical payments (Auto)
Medical payments
Physical Damage Coverages (Auto)
Physical Damage Coverages
Year, Make, Model Comprehensive Collision Roadside assistance Agreed Value
Please enter any specific quoting instructions for the auto policy below. (Auto)
Please enter any specific quoting instructions for the auto policy below.
Watercraft
Is this vessel currently insured? **
Is this vessel currently insured? *
- Yes
- No
What is the name of the insurance carrier?
What is the name of the insurance carrier?
Enter the year, make, model and length of the vessel. **
Enter the year, make, model and length of the vessel. *
Year Make Model Length
Vessel Type
What type of vessel is it?
Please describe the type of vessel.
Please describe the type of vessel.
What is the mast material? **
What is the mast material? *
Home Address
Please enter your home address.

Street Address Address Line 2 City State ZIP Code
Entity Ownership*
Is there a Trust, LLC, or Limited Partnership involved in the ownership of this vessel? *
- Yes
- No
Entity Name
What is the name of the trust, LLC, or Limited Partnership?
Are there any co-owners? * (Family or Non-Family)*
Are there any co-owners? * (Family or Non-Family)
- Yes
- No
How many co-owners are there? **
How many co-owners are there? *
Please enter a number from 0 to 20.
Please enter the requested information for the co-owners. *
Please enter the requested information for the co-owners. *
Full name Occupation/Employer Relation to you
Hull Details*
Please provide the requested information about the hull? *
Hull ID # Hull Material
# of engines? **
How many engines does the vessel have? *
Please enter a number from 0 to 10.
Engine Details*
Please provide the following information about the engine(s). *
Engine type (Inboard, Outboard, I/O) Year Built HP per Engine/CC's, if applicable
Engine Details 2
Please tell us more about the engine(s).
Engine Manufacturer Engine Serial # (Optional)
Fuel type? *
What type of fuel does the vessel use? *
What was the purchase price? * Watercraft*
What was the purchase price? *
What is the purchase date? **
What is the purchase date? *
MM slash DD slash YYYY
What is the value of this vessel? (Vessel & Engines) Watercraft*
What is the value of this vessel? (Vessel & Engines) *
Describe the type of vessels you have experience operating. **
Describe the type of vessels you have experience operating. *
How many people will operate this vessel? **
How many people will operate this vessel? *
Please enter a number greater than or equal to 0.
Vessel operators information*
Please enter the information requested below for each operator. *
Full Name Years of Experience Type of Experience Prior Vessels Owned
What is the vessel's maximum speed? **
What is the vessel's maximum speed? *
Do you currently or intend to use this vessel for charters? **
Do you currently or intend to use this vessel for charters? *
- Yes
- No
How many days per year will you charter this vessel? * Watercraft*
How many days per year will you charter this vessel? *
Navigation Area*
Please describe the waters to be navigated. (I.e. Coastal New England, Inland Lakes & Streams, etc.) *
Financing
Is the vessel financed or leased?
- Financed
- Leased
- No
Summer Marina Address
What is the address where the vessel is moored in the summer? *

Street Address Address Line 2 City State ZIP Code
How is the vessel stored in the summer? *
How is the vessel stored in the summer? *
What is the address where the vessel is moored in the winter?
What is the address where the vessel is moored in the winter? *

Street Address Address Line 2 City State ZIP Code
How is the vessel stored in the winter?
How is the vessel stored in the winter? *
Does the vessel have a layup period? *
Does the vessel have a layup period? *
- Yes
- No
How is the vessel stored during the lay-up period?
How is the vessel stored during the lay-up period?
- Ashore
- Afloat
What period is the boat in the water? **
What period is the boat in the water? *
Trailer?
Is there a trailer?
- Yes
- No
Trailer details: **
Please provide details about the trailer. *
Year, Make, Model Purchase Date Value Serial #, if available
Do you have a dinghy or other tender? **
Do you have a dinghy or other tender? *
- Yes
- No
Do you have a marine survey for this vessel?
Do you have a marine survey for this vessel?
- Yes
- No
Please upload the marine survey here.
Please upload the marine survey here. (Optional)
Drop files here or

Max. file size: 128 MB.
What equipment does this vessel have? * (Select all that apply)
What equipment does this vessel have? * (Select all that apply)
- Built-in Fire Extinguishing System
- Compass
- Ship to shore radio
- Depth finder
- Radar
- Bilge blowers
- EPIRB
- Fume detector/Carbon monoxide detector
- Alarm/monitoring system
- Propellor/hub locks
- Trailer hitch/axle locks
- RDF
- Loran
- Electronic chart plotter
Does the vessel have unrepaired damage or was it purchased as a salvage? **
Does the vessel have unrepaired damage or was it purchased as a salvage? *
- Yes
- No
Is the vessel used for racing? **
Is the vessel used for racing? *
- Yes
- No
Is the vessel currently for sale? **
Is the vessel currently for sale? *
- Yes
- No
Are any full-time or part-time crew employed in service of this vessel?*
Are any full-time or part-time crew employed in service of this vessel?
- Yes
- No
Is the vessel used for tubing or waterskiing? **
Is the vessel used for tubing or waterskiing? *
- Yes
- No
Please list any professional boating certifications you have.
Please list any professional boating certifications you have.
Have there been any marine claims or losses in the last 6 years? **
Have there been any marine claims or losses in the last 6 years? *
- Yes
- No
Please provide detail of the marine claims or losses below. **
Please provide detail of the marine claims or losses below. *
Please enter any additional comments about this vessel in the space below.
Please enter any additional comments about this vessel in the space below.
Watercraft (ADVISOR USE) - QUOTING INSTRUCTIONS
Hull limit - Property damage
Hull limit - Property damage
Hull deductibles (Open perils, lighting, windstorm, etc.)
Hull deductibles (Open perils, lighting, windstorm, etc.)
Medical payments (Watercraft)
Medical payments
Pollution and Indemnity liability (Watercraft)
Pollution and Indemnity liability
Uninsured boaters (Watercraft)
Uninsured boaters
Personal property (Watercraft)
Personal property
Please enter any specific quoting insurance for this watercraft policy below.
Please enter any specific quoting insurance for this watercraft policy below.
Toys (Golf carts, ATVs, Motorcycles, Snowmobiles)
Please select the types of toys you own. (Select all that apply) **
Please select the types of toys you own. (Select all that apply) *
- All Terrain Vehicle (ATV)
- Golf Cart
- Motorcycle
- Snowmobile
Do you have insurance in place for your toys? **
Do you have insurance in place for your toys? *
- Yes
- No
What is the name of the insurance carrier for your toys?
What is the name of the insurance carrier for your toys?
How many ATVs do you own? **
How many ATVs do you own? *
Please enter a number from 1 to 10.
How many golf carts do you own? **
How many golf carts do you own? *
Please enter a number from 1 to 10.
How many motorcycles do you own? **
How many motorcycles do you own? *
Please enter a number from 1 to 10.
How many snowmobiles do you own? **
How many snowmobiles do you own? *
Please enter a number from 1 to 10.
Please enter the requested information about your ATV(s). **
Please enter the requested information about your ATV(s). *
Year, Make, Model VIN States operated in Value CCs
Please enter the requested information about your golf cart(s). **
Please enter the requested information about your golf cart(s). *
Year, Make, Model VIN Registration State Value Driven on public roads?
Please enter the requested information about your motorcycle(s). **
Please enter the requested information about your motorcycle(s). *
Year, Make, Model VIN Registration State Value CCs
Please enter the requested information about your snowmobile(s). **
Please enter the requested information about your snowmobile(s). *
Year, Make, Model VIN States operated in Value CCs?
Are the ATVs/Snowmobiles operated on or off your own property? **
Are the ATVs/Snowmobiles operated on or off your own property? *
- Operated on my own property
- Operated off my own property
- Operated on and off my own property
Have there been any prior losses/claims with any of your toys? **
Have there been any prior losses/claims with any of your toys? *
- Yes
- No
Please provide details of any losses/claims with your toys below. **
Please provide details of any losses/claims with your toys below. *
Date Description Amount Paid
How many people will operate your toys? **
How many people will operate your toys? *
Please enter a number from 1 to 10.
Please enter the requested information about who will operate your toys. **
Please enter the requested information about who will operate your toys. *
Name Toys they will operate Years of experience
Toys Comments
Please enter any additional comments about your toys in the space below.
Toys (ADVISOR USE) - QUOTING INSTRUCTIONS
Bodily injury liability (Toys)
Bodily injury liability
Property damage liability (Toys)
Property damage liability
Uninsured/underinsured motorist (Toys)
Uninsured/underinsured motorist
Uninsured/underinsured property damage (Select states) (Toys)
Uninsured/underinsured property damage (Select states)
Personal injury protection (Select states) (Toys)
Personal injury protection (Select states)
Lawsuit option (Select states) (Toys)
Lawsuit option (Select states)
Medical payments (Toys)
Medical payments
Collision deductibles (Toys)
Collision deductibles
Comprehensive deductibles (Toys)
Comprehensive deductibles
Full glass (Toys)
Full glass
Rental reimbursement (Toys)
Rental reimbursement
Roadside assistance (Toys)
Roadside assistance
Please enter any specific quoting instructions for the toys policy below.
Please enter any specific quoting instructions for the toys policy below.
Personal Cyber Liability
In the last 5 years, have you faced any claims, complaints, or losses due to privacy or security breaches, identity theft, cyberattacks, or damage to third-party networks?*
In the last 5 years, have you faced any claims, complaints, or losses due to privacy or security breaches, identity theft, cyberattacks, or damage to third-party networks?
- Yes
- No
Please provide the details requested below about the claim(s), losses, or complaint(s). **
Please provide the details requested below about the claim(s), losses, or complaint(s). *
Date Nature of the claim, loss or complaint (I.e. Privacy breach, identity theft, cyberattack) Description
Are you aware of any incidents that could potentially lead to a claim or loss? * (I.e. Breaches, identity theft, cyberattacks)*
Are you aware of any incidents that could potentially lead to a claim or loss? * (I.e. Breaches, identity theft, cyberattacks)
- Yes
- No
Please provide a description of the incident you are aware of. **
Please provide a description of the incident you are aware of. *
In the last 5 years, have you experienced any financial losses from fraud, theft, or cyber breaches? **
In the last 5 years, have you experienced any financial losses from fraud, theft, or cyber breaches? *
- Yes
- No
Please provide the details requested below about the financial loss from fraud, theft, or cyber breaches. **
Please provide the details requested below about the financial loss from fraud, theft, or cyber breaches. *
Date Description (I.e. Fraud, theft, cyber breach) Steps taken to recover
Personal Cyber Liability (ADVISOR USE) - QUOTING INSTRUCTIONS
Cyber liability (Personal Cyber)
Cyber liability
Please enter any specific quoting instructions for cyber liability below. (Cyber)
Please enter any specific quoting instructions for cyber liability below.
Personal Excess Liability / Umbrella
Do you have personal excess liability/umbrella insurance in place?*
Do you have personal excess liability/umbrella insurance in place?
- Yes
- No
What is the name of your current insurance carrier?
What is the name of your current insurance carrier?
When was the last time you reviewed your umbrella policy limit?
When was the last time you reviewed your umbrella policy limit?
Do you own or regularly use any boats, cycles, golf carts, atvs, snowmobiles, mopeds, etc.?*
Do you own or regularly use any boats, cycles, golf carts, atvs, snowmobiles, mopeds, etc.?
- Yes
- No
How many watercraft/recreational vehicles do you own? **
How many watercraft/recreational vehicles do you own? *
Please enter a number from 1 to 25.
Do you or your family take any high risk travel?*
Do you or your family take any high risk travel?
- Yes
- No
Do you serve as a trustee in any capacity?*
Do you serve as a trustee in any capacity?
- Yes
- No
Do you conduct business from your home? **
Do you conduct business from your home? *
- Yes
- No
Is there customer foot traffic?*
Is there customer foot traffic?
- Yes
- No
Would you like to learn more about kidnap and ransom coverage?
Would you like to learn more about kidnap and ransom coverage?
- Yes
- No
Do any household members sit on any boards, or volunteer time/services for non-profits in any official capacity? **
Do any household members sit on any boards, or volunteer time/services for non-profits in any official capacity? *
- Yes
- No
Do you have any ownership in any aircraft (even fractional) or do you charter them? (I.e. NetJets, Jet Partners, etc.)
Do you have any ownership in any aircraft (even fractional) or do you charter them? (I.e. NetJets, Jet Partners, etc.)
- Yes
- No
Do you have any consistently employed household staff? (I.e. housekeeping, nanny/childcare, chauffeur, chefs, etc.) **
Do you have any consistently employed household staff? (I.e. housekeeping, nanny/childcare, chauffeur, chefs, etc.) *
- Yes
- No
How many hours do they work per week? **
How many hours do they work per week? *
Do you carry any of the following coverages? (Workers compensation, disability, employer practices liability)*
Do you carry any of the following coverages? (Workers compensation, disability, employer practices liability)
- Yes
- No
Personal Umbrella Notes
Please enter any notes about your excess liability/umbrella coverage below. (I.e You have a group excess liability policy, previous claims, proposal coverage limit requests, etc.)
Personal Excess Liability/Umbrella (ADVISOR USE) - QUOTING INSTRUCTIONS
Bodily injury and property damage (Umbrella)
Bodily injury and property damage
Uninsured/Underinsured Motorist (Umbrella)
Uninsured/Underinsured Motorist
Uninsured/Underinsured (Umbrella)
Uninsured/Underinsured
Employment practices liability (Umbrella)
Employment practices liability
Not-for-profit directors and officers (Umbrella)
Not-for-profit directors and officers
Please enter any specific quoting instructions for the personal excess liability/umbrella below. (Umbrella)
Please enter any specific quoting instructions for the personal excess liability/umbrella below.
Documents and Comments
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, by-laws of the association, jewelry appraisals, etc...)
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, by-laws of the association, jewelry appraisals, etc...)
Drop files here or

Max. file size: 128 MB, Max. files: 25.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
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.

Consumer disclosure: By checking the box below you authorize Gallagher personnel 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.
I agree *

Alex Moreno CIC, CPRIA

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Date	Description	Amount Paid

Project Description	Square Foot	Value of Work ($)

Date	Description

How many pieces	Total collection value	Value of most significant piece

Gallagher Test Form v5.0

Personal Insurance Program Structure

Location 1

Flood Insurance - Location 1

Location 1 - Wind Coverage

Location 1 - Wildfire Risk Questions

(ADVISOR USE) - Location 1 Coverage Limits

Location 2

Location 3

Location 4

New Construction/Renovation (Home/Condominium/Cooperative)

General Project Information

Project Schedule

Interested Parties

General Contractor

General Contractor Information

Risk Management on Site

Valuable Articles

Valuable Articles (ADVISOR USE) - QUOTING INSTRUCTIONS

Automobile

Vehicle Information

Driver Information

Automobile (ADVISOR USE) - QUOTING INSTRUCTIONS

Watercraft

Watercraft (ADVISOR USE) - QUOTING INSTRUCTIONS

Toys (Golf carts, ATVs, Motorcycles, Snowmobiles)

Toys (ADVISOR USE) - QUOTING INSTRUCTIONS

Personal Cyber Liability

Personal Cyber Liability (ADVISOR USE) - QUOTING INSTRUCTIONS

Personal Excess Liability / Umbrella

Personal Excess Liability/Umbrella (ADVISOR USE) - QUOTING INSTRUCTIONS

Documents and Comments

Alex Moreno CIC, CPRIA

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