What is your first name? *
What is your last name? *
What is your preferred phone number? *
Please enter your email. *
Please enter the address of the location you would like an insurance proposal for. *
Are you in the process of purchasing this home? *
What is the purchase price? *
What is the date of closing? *
MM slash DD slash YYYY
When do you need this coverage to start? *
MM slash DD slash YYYY
What is the name of your current insurance company? *
Will you do any renovations to this home immediately after you purchase it and prior to moving in? *
Do you have plans to do any renovations at this home in the near future? *
What is the approximate budget for the renovation?
How long will the renovation take?
Please select the intended occupancy of this property.
Please select the frequency of rentals for this home.
What will the occupancy of this home be?
Will you be renting this home to others? *
Will you be selling your current residence? *
What date will you sell your current residence?
MM slash DD slash YYYY
Please provide a brief explanation of your plans for your current home.
Will there be a mortgage? *
What is the name of the bank providing the mortgage?
Who is 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?
Will the insurance premium be escrowed?
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What is the name of your current insurance carrier?
Is there a mortgage? *
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient.
Please enter the loan number, if convenient.
Is the insurance premium being escrowed?
Is there a second mortgage or home equity loan?
Is there a Trust, LLC or Limited Partnership involved in the ownership of this property? *
Please enter the name of the Trust, LLC or Limited Partnership: *
What is the purpose of the Trust, LLC or Limited Partnership? *
Is there a monitored alarm system in this home? *
Select the components of your monitored alarm system. *
What other components does your alarm system have?
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Please upload a copy of your alarm certificate, if available.
Please select the risk mitigation features of this property.
Enter the other risk mitigation feature(s) in this home.
What is the approximate square footage of this home? (Do not include the basement square footage, if any.) *
What year was this home built? (YYYY) *
How many stories does this home have?
How many full bathrooms does this home have? *
How many half bathrooms does this home have? *
What is the age of your roof? (YYYY)
Please select your roof type:
Please provide a description of your roof type:
Please select the construction type of the home.
What is the construction type of your home? (Ex. Frame, masonry)
Select the features of your home that have been updated.
What other updates have been done to your home?
What year was the electrical updated?
What year was the plumbing updated?
What year was the heating system updated?
What year was the roof updated?
What year were the windows updated?
What type of foundation does the home have? *
What percentage of the basement is finished? (ex. 100%) *
What is the approximate square footage of the entire basement? *
Please select the other structures on this property.
Enter a brief description of the other structure(s) on this property.
Is the pool completely fenced in?
Is there a diving board or slide attached to the pool?
Is there an attached garage?
How many car bays does the attached garage have?
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 many solar panels are there?
Where are the solar panels located? (Check all that apply)
Do you own or lease the solar panels?
Are you responsible for insuring the panels?
What is the value of the solar panels? *
Additional Considerations
Have there been any insurance claims at this residence? *
Please provide details about the insurance claims at this residence. *
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. *
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? *
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? *
Would you like a proposal for extended mold remediation coverage?
Would you like a proposal for earthquake insurance?
Do you plan to sell an existing residence? *
Please enter the address of the home you plan to sell.
Documents and Comments
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.
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.
