Homeowners Insurance Excess and Surplus Lines Basic Form

Select a description for this phone number?

What is your gender?

Select a description for this phone number?

What is their gender?

Please select the applicable residence type.

Please select the occupancy of this residence.

How is this property used?

Is there any construction underway or set to begin at this residence?

Please select a description for the construction at this residence.

Was the wiring renovation partial or complete?

Was the plumbing renovation partial or complete?

Was the heating renovation partial or complete?

Was the roofing renovation partial or complete?

Are there any known leaks at this residence?

Does this residence have a primary heating system?

Does this residence have a secondary heating system?

What type of wiring does this residence have?

Does this residence have circuit breakers or fuses?

Please select the option that best describes the foundation.

Does this residence have a fuel tank?

Does this residence have a fire suppression sprinkler system?

Is the fire suppression sprinkler system partial or complete?

How would you measure this residence’s distance to tidal water?

Does this residence have storm shutters?

Select the type of storm shutters.

What is this residence’s wind class?

Are you in the process of purchasing this residence?

Select the desired coverage option for loss of use?

Is the All Other Perils (AOP) deductible a dollar amount or percentage?

Is the wind/hail deductible a dollar amount or percentage?

Is the theft deductible a dollar amount or percentage?

Is the named storm deductible a dollar amount or percentage?

Is the annual hurricane deductible a dollar amount or percentage?

Is the Other (Write in) deductible a dollar amount or percentage?

Do you want to include incidental farming personal liability coverage in this policy?

Have you had any losses, whether or not paid by insurance, during the last seven years, at this or any location?

Is this loss being disputed?

Is there another claim?

Is this loss being disputed?

Is there another claim?

Is this loss being disputed?

Is there another claim?

Is this loss being disputed?

Did you previously have insurance for this residence?

Do you have any other insurance with this company/agency?

Has any coverage been declined, canceled or non-renewed during the last three (3) years? (Missouri Applicants - Do not answer this question)

Have you (the Applicant) had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past five (5) years?

Have you (the Applicant) had a judgement or lien during the past (5) years?

Is any other residence, not listed on any application, owned, occupied or rented?

Has insurance been transferred within the agency?

Do you (the Applicant) own any recreational vehicles (Snow mobiles, dune buggies, mini bikes, ATVs, etc.) not scheduled on this policy?

During the last five (5) years [Ten (10) years in Rhode Island], have you (any Applicant) been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with the or any other property? (In RI, failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one (1) year of imprisonment.)

Is any business conducted on the premises?

Do you (the Applicant) have any residence employees?

Is there any flooding, brush, forest fire or landslide hazard at this residence?

Are there any animals or exotic pets kept on premises?

Is the property situated on more than one acre?

Are there any uncorrected fire or building code violations?

Is the dwelling/home for sale?

Is the property within 300 feet of a commercial or non-residential property?

Is there a trampoline on premises?

Does the trampoline have a safety net?

Was the structure originally built to be other than a private residence and then converted to a private residence?

Is there any lead paint?

If a fuel tank is on premises, has other insurance been obtained for the tank?

Is the residence in a gated community?

If the building is under construction, are you (the Applicant) the general contractor?

Will the construction include any structural changes to the residence?

Do you (the Applicant) want to include or exclude coverage for building materials that are not yet attached to the residence?

Will the residence be occupied during the construction?

Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes? (Illinois - 15ft)

Are you (the Applicant) the owner of the property?

Is there a manager on the premises?

Is there a security attendant?

Is the building entrance locked?

Is there an additional interest to be added to this policy?

Is there a second additional interest?

Who will the policy be mailed to?

Who is the payor?

Will this policy use premium financing?