What is your first name?*
What is your last name?*
What is your preferred phone number?*
What is your email address?*
What is your date of birth?*
MM slash DD slash YYYY
What is your marital status?*
What is your spouse's full name?
What is your partner's full name?
What is your fiancé's full name?
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Please enter their occupation and employer name:
Please enter their occupation.
Please enter their employer.
Please enter their date of birth.
MM slash DD slash YYYY
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?
Please select the intended occupancy of the property you are purchasing.
Please describe the intended occupancy of the home you are purchasing.
Please select the occupancy of this property.
What is the occupancy of this home?
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What is your current home address?
What is your primary home address?
Have you lived at your current address for three or more years?
Have you lived at your primary home address for three or more years?
Please provide the address where you lived prior to your current address?
Please provide the address where you lived prior to your current address?
Will you renovate this home after you purchase it?
Do you have plans to do a renovation at this home?
What is the approximate budget for the renovation?
How long will the renovation take?
Please provide a brief description of your renovation plans.
Please select the frequency of rentals for this home.
Will there be a mortgage?
What is the name of the bank/institution 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?
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, Limited Partnership or other legal entity involved in the ownership of this property?
Legal Entity Information
What is the name of the legal entity?
What type of legal entity is it?
Please enter the type of legal entity:
What is the mailing address for the legal entity?
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
What is the purpose or intent of the entity?
Does the entity generate income or conduct business with regards to the appreciation of owned property, private residential rental income, management of wealth for the benefit of the principal owners or incidental business?
Please provide details about the income generation and business conducted by this entity.
Does the entity generate income in any other ways?
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees?
Please list the name and occupation for each of the employees:
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies?
Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Residence Information
Is there an alarm system in this home?
Select the components of your alarm system.
What other components does your alarm system have?
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.
Has a 4-point inspection been done on this home?*
Please upload a copy of the 4-point inspection, if available.
Has a windstorm/wind mitigation inspection been done on this home?*
Please upload a copy of the windstorm/wind mitigation certificate, if available.
What is the approximate square footage of this home?
What year was this home built?
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What year was this home built?
How many stories does this home have?
What is the age of your roof?
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?
Select the infrastructure elements 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 were the windows updated?
What year was the home's water heater installed? * (YYYY)
What type of heating system does the home have?
Please describe the heating system.
Where is the oil tank located?
What type of foundation does the home have?
What percentage of the basement is finished? (ex. 100%)
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/enclosed?
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?*
Please select the items below that are present or will be present at this home. (Select all that apply)
Is there safety netting around the trampoline?
What breed of dog do you have?
Please select the type of wood burning stove you have:
What type of wood burning stove do you have?
How many fireplaces are there?
Please select the type(s) of fireplaces in the home.
Please select the types of valuable property you own.
Please tell us about your jewelry.
Please tell us about your fine art.
Please tell us about your other valuable items.
Would you like to include sink hole coverage in your proposal?
Would you like to include mold/fungi coverage in your proposal?
Have there been any insurance claims at this location in the last five years? *
Please provide details about any insurance claim(s) at this location in the last five years. *
Do you plan to sell an existing residence? *
Please enter the address of the home you plan to sell.
Would you like a flood insurance proposal for your home?
Flood Insurance Information
Has the home been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)
Please describe where the machinery for this residence is located.
Where is your personal property kept at this location?
Please describe where the personal property is kept at this location.
Does this home have flood vents?
Do you have a flood insurance policy in place today?
Please upload a copy of your Flood insurance policy, if available.
Have you been paid over $5,000 on any flood claims in the last 10 years?
Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.
Is your policy being cancelled or non-renewed?
Please tell us your insurer's reason for cancelling or non-renewing your policy.
Do you have an elevation certificate for this property? *
Please upload a copy of the elevation certificate
Have there been any flood insurance claims at this residence?
Please provide details about the flood insurance claims at this residence.
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, home inspection, 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.
