Insured 1 - First Name* What is your first name? *
Insured 1 - Last Name* What is your last name? *
Insured 1 - Phone Number* What is your preferred phone number? *
Email* Please enter your email. *
Please enter the address of the location you would like an insurance proposal for. ** Please enter the address of the location you would like an insurance proposal for. *
New Purchase?* Are you in the process of purchasing this home? *
Purchase Price* What is the purchase price? *
What is the date of closing? ** What is the date of closing? *
MM slash DD slash YYYY
When do you need this coverage to start? ** When do you need this coverage to start? *
MM slash DD slash YYYY
What is the name of your current insurance company? ** What is the name of your current insurance company? *
Major Renovation* Will you do any renovations to this home immediately after you purchase it and prior to moving in? *
Major Renovation Current Home* Do you have plans to do any renovations at this home in the near future? *
Renovation Budget What is the approximate budget for the renovation?
Renovation Time Frame How long will the renovation take?
Occupancy Please select the intended occupancy of this property.
Please select the frequency of rentals for this home. Please select the frequency of rentals for this home.
Occupancy other What will the occupancy of this home be?
Will you be renting this home to others? ** Will you be renting this home to others? *
Plans for Current Residence* Will you be selling your current residence? *
Current Residence Sale Date What date will you sell your current residence?
MM slash DD slash YYYY
Current Home Plans Please provide a brief explanation of your plans for your current home.
Will there be a mortgage? ** Will there be a mortgage? *
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?
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What is the name of your current insurance carrier? What is the name of your current insurance carrier?
Is there a mortgage? ** Is there a mortgage? *
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.
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?
Second mortgage/Home Equity Loan Is there a second mortgage or home equity loan?
Trust or LLC* Is there a Trust, LLC or Limited Partnership involved in the ownership of this property? *
Trust or LLC Name* Please enter the name of the Trust, LLC or Limited Partnership: *
Trust or LLC Purpose* What is the purpose of the Trust, LLC or Limited Partnership? *
Alarm System* Is there a monitored alarm system in this home? *
Alarm System Components* Select the components of your monitored alarm system. *
Alarm What other components does your alarm system have?
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Alarm Certificate Upload Please upload a copy of your alarm certificate, if available.
Risk Mitigation Features Please select the risk mitigation features of this property.
Risk Mitigation Other Enter the other risk mitigation feature(s) in this home.
Home Square Footage* What is the approximate square footage of this home? (Do not include the basement square footage, if any.) *
Year Built* What year was this home built? (YYYY) *
How many stories does this home have? How many stories does this home have?
How many full bathrooms does this home have? ** How many full bathrooms does this home have? *
How many half bathrooms does this home have? ** How many half bathrooms does this home have? *
What is the age of your roof? (YYYY) What is the age of your roof? (YYYY)
Please select your roof type: Please select your roof type:
Please provide a description of your roof type: Please provide a description of your roof type:
Construction Type Please select the construction type of the home.
Construction Type Other? What is the construction type of your home? (Ex. Frame, masonry)
System/features Updates Select the features of your home 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?
Roof update year What year was the roof updated?
Windows update year What year were the windows updated?
Foundation type* What type of foundation does the home have? *
Finished basement percentage* What percentage of the basement is finished? (ex. 100%) *
Total Basement Square Footage* What is the approximate square footage of the entire basement? *
Property Structures Please select the other structures on this property.
Other Property Structures Enter a brief description of the other structure(s) on this property.
Pool fenced? Is the pool completely fenced in?
Pool diving board or slide? Is there a diving board or slide attached to the pool?
Attached garage? Is there an attached garage?
Attached garage car bays? How many car bays does the attached garage have?
Does this home include solar panels? ** Does this home include solar panels? *
Solar Panel Information How is the power generated by the solar panels being used? (Check all that apply) How is the power generated by the solar panels being used? (Check all that apply)
How many solar panels are there? How many solar panels are there?
Where are the solar panels located? (Check all that apply) Where are the solar panels located? (Check all that apply)
Do you own or lease the solar panels? Do you own or lease the solar panels?
Are you responsible for insuring the panels? Are you responsible for insuring the panels?
What is the value of the solar panels? ** What is the value of the solar panels? *
Additional Considerations Have there been any insurance claims at this residence? ** Have there been any insurance claims at this residence? *
Please provide details about the insurance claims at this residence. ** Please provide details about the insurance claims at this residence. *
Flood insurance? Would you like a proposal for surface water / flood insurance?
Please select the option that best describes your basement. ** Please select the option that best describes your basement. *
Please select the option that best describes your basement. ** Please select the option that best describes your basement. *
Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) ** Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) *
Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) ** Is there machinery that services the building in the basement? (E.g. Central air conditioner (Including external compressor), Furnace, Hot Water Heater, Heat Pump, Including external compressor), Elevator Machinery and Equipment) *
What is the approximate value of the machinery that services the building? ** What is the approximate value of the machinery that services the building? *
What is the approximate value of the machinery that services the building? ** What is the approximate value of the machinery that services the building? *
Are there any washers/dryers/food freezers located in the basement? ** Are there any washers/dryers/food freezers located in the basement? *
Are there any washers/dryers/food freezers located in the basement? ** Are there any washers/dryers/food freezers located in the basement? *
What is the approximate value of the washers/dryers/food freezers located in the basement? ** What is the approximate value of the washers/dryers/food freezers located in the basement? *
What is the approximate value of the washers/dryers/food freezers located in the basement? ** What is the approximate value of the washers/dryers/food freezers located in the basement? *
Mold remediation insurance? Would you like a proposal for extended mold remediation coverage?
Earthquake insurance? Would you like a proposal for earthquake insurance?
Do you plan to sell an existing residence? ** Do you plan to sell an existing residence? *
Please enter the address of the home you plan to sell. Please enter the address of the home you plan to sell.
Documents and Comments Uploaded Documents Please use this field to upload any other relevant information for this new residence. (i.e. home inspection, mortgage requirements, elevation certificates, wind mitigation form, etc.).
Please enter any additional remarks in the space below. Please enter any additional remarks in the space below.
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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