Homeowners Insurance - Current Client

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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. *

Street Address Address Line 2 City State ZIP Code
New Purchase?*
Are you in the process of purchasing this home? *
- Yes
- No
Purchase Price*
What is the purchase price? *
What is the date of closing? **
What is the date of closing? *
When do you need this coverage to start? **
When do you need this coverage to start? *
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? *
- Yes
- No
Major Renovation Current Home*
Do you have plans to do any renovations at this home in the near future? *
- Yes
- No
Renovation Budget
What is the approximate budget for the renovation?
Renovation Time Frame
How long will the renovation take?
- 1 to 3 months
- 3 to 6 months
- 6 to 12 months
- 1 to 2 years
Occupancy
Please select the intended occupancy of this property.
- Primary residence
- Secondary residence
- Rented to others (long-term, short-term, or seasonal tenants)
- Unoccupied
- Vacant (No contents)
- Under construction/renovation
- Other
Please select the frequency of rentals for this home.
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...
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? *
- Yes
- No
- Not sure
Plans for Current Residence*
Will you be selling your current residence? *
- Yes
- No
Current Residence Sale Date
What date will you sell your current residence?
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? *
- Yes
- No
What is the name of the bank providing the mortgage?
What is the name of the bank providing the mortgage?
Who is your contact at the bank?
Who is your contact at the bank?
What is the phone number for your contact at the bank?
What is the phone number for your contact at the bank?
What is the email address for your contact at the bank?
What is the email address for your contact at the bank?
Will the insurance premium be escrowed?
Will the insurance premium be escrowed?
- Yes
- No
- Not sure
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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? *
- 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
Second mortgage/Home Equity Loan
Is there a second mortgage or home equity loan?
- Yes
- No
Trust or LLC*
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property? *
- Yes
- No
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? *
- Yes
- No
- A monitored alarm system will be professionally installed after the closing.
Alarm System Components*
Select the components of your monitored alarm system. *
- Centrally monitored fire alarm
- Centrally monitored burglar alarm
- Heat/Smoke detectors
- Burglar motion sensors
- Low temperature monitor
- Water leak detection
- 24-hour signal continuity (Backup communication method)
- 24-hour professionally monitored video surveillance
- Gas leak detection
- Other
Alarm
What other components does your alarm system have?
This field is hidden when viewing the form
Alarm Certificate Upload
Please upload a copy of your alarm certificate, if available.
Max. file size: 128 MB.
Risk Mitigation Features
Please select the risk mitigation features of this property.
- Stand-by back-up generator
- Indoor sprinkler system
- Automatic water shut-off valve
- Water leak detection system
- Lightning protection system
- Gated house
- Gated community
- Perimeter fencing
- Permanently installed safe
- Flood vents
- Seismic shut-off valve
- LEED Certified
- None
- Other
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:
- Asphalt Shingle
- Architectural Shingle
- Wood Shingle
- Metal Roof
- Flat Roof
- Rubber Roof
- Cement Tile
- Clay Tile
- Other
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.
- Wood frame
- Brick
- Masonry
- Joisted Masonry
- Stucco
- Steel
- Not Sure
- Other
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.
- Electrical
- Plumbing
- Heating
- Roof
- Windows
- None
- Other
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
- Unfinished basement
- Slab
- Stilts
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.
- Pool
- Pool house
- Fence
- Detached garage
- Guest house
- Jungle gym
- Dock
- Stone walls
- Barn
- Shed
- Tennis court
- None
- Other
Other Property Structures
Enter a brief description of the other structure(s) on this property.
Pool fenced?
Is the pool completely fenced in?
- Yes
- No
Pool diving board or slide?
Is there a diving board or slide attached to the pool?
- Yes
- No
Attached garage?
Is there an attached garage?
- Yes
- No
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? *
- Yes
- No
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)
- Home Power Generation
- Pool Heating
- Other
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)
- Roof of the Main Dwelling
- Roof of a Secondary Structure
- Ground Mounted
- Other
Do you own or lease the solar panels?
Do you own or lease the solar panels?
- Own
- Lease
Are you responsible for insuring the panels?
Are you responsible for insuring the panels?
- Yes
- No
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? *
- Yes
- No
Please provide details about the insurance claims at this residence. **
Please provide details about the insurance claims at this residence. *
Date of Loss Brief description Amount Paid ($)
Flood insurance?
Would you like a proposal for surface water / flood insurance?
- Yes
- No
Please select the option that best describes your basement. **
Please select the option that best describes your basement. *
- Basement
- Split Level Basement
- Walkout Basement
- None of these
Please select the option that best describes your basement. **
Please select the option that best describes your basement. *
- Basement
- Split Level Basement
- Walkout Basement
- None of these
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) *
- Yes
- No
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) *
- Yes
- No
What is the approximate value of the machinery that services the building? **
What is the approximate value of the machinery that services the building? *
- $1,000 - $10,000
- $10,000 - $20,000
- Over $20,000
What is the approximate value of the machinery that services the building? **
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? **
Are there any washers/dryers/food freezers located in the basement? *
- Yes
- No
Are there any washers/dryers/food freezers located in the basement? **
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? **
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
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? *
- $1,000 - $5,000
- $5,000 - $10,000
- Over $10,000
Mold remediation insurance?
Would you like a proposal for extended mold remediation coverage?
- Yes
- No
Earthquake insurance?
Would you like a proposal for earthquake insurance?
- Yes
- No
Do you plan to sell an existing residence? **
Do you plan to sell an existing residence? *
- Yes
- No
- I do not own another residence
Please enter the address of the home you plan to sell.
Please enter the address of the home you plan to sell.

Street Address Address Line 2 City State ZIP Code
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.).
Drop files here or

Max. file size: 128 MB.
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.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
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Homeowners Insurance - Current Client

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Date of Loss	Brief description	Amount Paid ($)

Homeowners Insurance - Current Client

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Brian Cook

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