Homeowners Insurance Florida Form - Valiant Group

What is your first name? **
What is your first name? *
What is your last name? **
What is your last name? *
What is your preferred phone number? **
What is your preferred phone number? *
What is your email address? **
What is your email address? *
What is your occupation?
What is your occupation?
What is the name of your employer?
What is the name of your employer?
What is your date of birth? **
What is your date of birth? *
MM slash DD slash YYYY
What is your marital status? **
What is your marital status? *
What is your spouse's full name?
What is your spouse's full name?
What is your partner's full name?
What is your partner's full name?
What is your fiancé's full name?
What is your fiancé's full name?
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Other Insured's Occupation & Employer
Please enter their occupation and employer name:
Please enter their occupation.
Please enter their occupation.
Please enter their employer.
Please enter their employer.
Please enter their date of birth.
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.*
Please enter the address of the location you would like an insurance proposal for. *

Street Address Address Line 2 City State ZIP Code
Are you in the process of purchasing this home?*
Are you in the process of purchasing this home? *
- Yes
- No
What is the 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?
Please select the intended occupancy of the property you are purchasing.
Please select the intended occupancy of the property you are purchasing.
- Primary residence
- Secondary residence
- Rented to others (long-term, short-term, or seasonal tenants)
- Unoccupied
- Vacant (No contents)
- Under construction/renovation
- Other
Please describe the intended occupancy of the home you are purchasing.
Please describe the intended occupancy of the home you are purchasing.
Please select the occupancy of this property.
Please select the occupancy of this property.
- Primary residence
- Secondary residence
- Rented to others (long-term, short-term, or seasonal tenants)
- Unoccupied
- Vacant (No contents remain)
- Under construction/renovation
- Other
What is the occupancy of this home?
What is the occupancy of this home?
This field is hidden when viewing the form
What is your current home address?
What is your current home address?

Street Address Address Line 2 City State ZIP Code
What is your primary home address?
What is your primary home address?

Street Address Address Line 2 City State ZIP Code
Have you lived at your current address for three or more years?
Have you lived at your current address for three or more years?
- Yes
- No
Have you lived at your primary home address for three or more years?
Have you lived at your primary home address for three or more years?
- Yes
- No
Please provide the address where you lived prior to your current address?
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Please provide the address where you lived prior to your current address?
Please provide the address where you lived prior to your current address?

Street Address Address Line 2 City State ZIP Code
Will you renovate this home after you purchase it?
Will you renovate this home after you purchase it?
- Yes
- No
Do you have plans to do a renovation at this home?
Do you have plans to do a renovation at this home?
- Yes
- No
What is the approximate budget for the renovation?
What is the approximate budget for the renovation?
How long will the renovation take?
How long will the renovation take?
- Less than 30 days
- 1 to 3 months
- 3 to 6 months
- 6 to 12 months
- 1 to 2 years
Please provide a brief description of your renovation plans.
Please provide a brief description of your renovation plans.
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...
Will there be a mortgage?
Will there be a mortgage?
- Yes
- No
What is the name of the bank/institution providing the mortgage?
What is the name of the bank/institution 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?
Mortgage Contact Email?
What is the email address for your contact at the bank?
Premium Escrowed?
Will the insurance premium be escrowed?
- Yes
- No
- Not sure
Current Mortgage?
Is there a mortgage?
- Yes
- No
Bank Name Current Insurance
Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Bank Address Current Insurance
Please enter the bank address, if convenient.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Loan Number Current Insurance
Please enter the loan number, if convenient.
Premium Escrowed Current Insurance
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
Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?
Is there a Trust, LLC, Limited Partnership or other legal entity involved in the ownership of this property?
- Yes
- No
Legal Entity Information
What is the name of the legal entity?
What is the name of the legal entity?
What type of legal entity is it?
What type of legal entity is it?
Please enter the type of legal entity:
Please enter the type of legal entity:
What is the mailing address for the legal entity?
What is the mailing address for the legal entity?

Street Address Address Line 2 City State ZIP Code
Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
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.
Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
Principal/Beneficial Owner Name/Trustee(s) Relationship to you
What is the purpose or intent of the entity?
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?
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?
- Yes
- No
Please provide details about the income generation and business conducted by this entity.
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 generate income in any other ways?
- Yes
- No
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
- Yes
- No
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Does the entity have any employees?
Does the entity have any employees?
- Yes
- No
Please list the name and occupation for each of the employees:
Please list the name and occupation for each of the employees:
Name Occupation
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Does the entity maintain any other insurance policies?
Does the entity maintain any other insurance policies?
- Yes
- No
Please provide the insurance company name(s), coverage type and coverage limits for the other 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?
Is there an alarm system in this home?
- Yes
- No
Select the components of your alarm system.
Select the components of your 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
- 24-hour professionally monitored video surveillance
- Gas leak detection
- Other
What other components does your alarm system have?
What other components does your alarm system have?
Please upload a copy of your alarm certificate, if available.
Please upload a copy of your alarm certificate, if available.
Max. file size: 128 MB.
Please select the risk mitigation features of this property.
Please select the risk mitigation features of this property.
- Stand-by back-up generator
- Fire Suppression Sprinkler System
- Automatic water shut-off valve
- Lightning protection system
- Gated house
- Gated community
- Perimeter fencing
- Permanently installed safe
- Flood vents
- Seismic shut-off valve
- LEED Certified
- None
- Other
Enter the other risk mitigation feature(s) in this home.
Enter the other risk mitigation feature(s) in this home.
Has a 4-point inspection been done on this home? **
Has a 4-point inspection been done on this home? *
- Yes
- No
- Not sure
Please upload a copy of the 4-point inspection, if available.
Please upload a copy of the 4-point inspection, if available.
Max. file size: 128 MB.
Has a windstorm/wind mitigation inspection been done on this home? **
Has a windstorm/wind mitigation inspection been done on this home? *
- Yes
- No
- Not sure
Please upload a copy of the windstorm/wind mitigation certificate, if available.
Please upload a copy of the windstorm/wind mitigation certificate, if available.
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.
What is the approximate square footage of this home?
What is the approximate square footage of this home?
What year was this home built?
What year was this home built?
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What year was this home built?
What year was this home built?
How many stories does this home have?
How many stories does this home have?
What is the age of your roof?
What is the age of your roof?
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:
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?

Please select the construction type of the home.
Please select the construction type of the home.
- Wood frame
- Brick
- Masonry
- Joisted Masonry
- Stucco
- Steel
- Not Sure
- Other
What is the construction type of your home?
What is the construction type of your home?
Select the infrastructure elements of your home that have been updated.
Select the infrastructure elements of your home that have been updated.
- Electrical
- Plumbing
- Heating
- Windows
- None
- Other
What other updates have been done to your home?
What other updates have been done to your home?
What year was the electrical updated?
What year was the electrical updated?
Plumbing update year
What year was the plumbing updated?
What year was the heating system updated?
What year was the heating system updated?
What year were the windows updated?
What year were the windows updated?
What year was the home's water heater installed? * (YYYY)*
What year was the home's water heater installed? * (YYYY)
What type of heating system does the home have?
What type of heating system does the home have?
Please describe the heating system.
Please describe the heating system.
Where is the oil tank located?
Where is the oil tank located?
- Basement
- Outside - above ground
- Outside - underground
What type of foundation does the home have?
What type of foundation does the home have?
- Finished basement
- Unfinished basement
- Walkout
- Slab
- Stilts
- Crawlspace
What percentage of the basement is finished? (ex. 100%)
What percentage of the basement is finished? (ex. 100%)
Please select the other structures on this property.
Please select the other structures on this property.
- Pool
- Pool house
- Pool enclosure
- Fence
- Detached garage
- Guest house
- Jungle gym
- Dock
- Stone walls
- Barn
- Shed
- Tennis court
- None
- Other
Enter a brief description of the other structure(s) on this property.
Enter a brief description of the other structure(s) on this property.
Is the pool completely fenced/enclosed?
Is the pool completely fenced/enclosed?
- Yes
- No
Is there a diving board or slide attached to the pool?
Is there a diving board or slide attached to the pool?
- Yes
- No
Is there an attached garage?
Is there an attached garage?
- Yes
- No
How many car bays does the attached garage have?
How many car bays does the attached garage have?
Please select the items below that are present or will be present at this home. (Select all that apply)
Please select the items below that are present or will be present at this home. (Select all that apply)
- Trampoline
- Dog
- Wood burning/ stove
- Fireplace
- None
Is there safety netting around the trampoline?
Is there safety netting around the trampoline?
- Yes
- No
What breed of dog do you have?
What breed of dog do you have?
Please select the type of wood burning stove you have:
Please select the type of wood burning stove you have:
- Insert
- Free standing
- Pellet stove
- Other
What type of wood burning stove do you have?
What type of wood burning stove do you have?
How many fireplaces are there?
How many fireplaces are there?
Please select the type(s) of fireplaces in the home.
Please select the type(s) of fireplaces in the home.
- Wood burning
- Gas
- Both - wood burning and gas
Please select the types of valuable property you own.
Please select the types of valuable property you own.
- Jewelry
- Fine art
- Other
- None
Please tell us about your jewelry.
Please tell us about your jewelry.
Total collection value ($) Number of items Value of most significant item ($)
Please tell us about your fine art.
Please tell us about your fine art.
Total collection value ($) Number of items Value of most significant item ($)
Please tell us about your other valuable items.
Please tell us about your other valuable items.
Description Total collection value ($) Value of most significant item ($)
Would you like to include sink hole coverage in your proposal?
Would you like to include sink hole coverage in your proposal?
- Yes
- No
- Not sure
Would you like to include mold/fungi coverage in your proposal?
Would you like to include mold/fungi coverage in your proposal?
- Yes
- No
- Not sure
Have you had any insurance claims in the last five (5) years at ANY locations you have owned in that time? **
Have you had any insurance claims in the last five (5) years at ANY locations you have owned in that time? *
- Yes
- No
Please provide details about the insurance claim(s) from the last five (5) years at ANY location you have owned/rented. **
Please provide details about the insurance claim(s) from the last five (5) years at ANY location you have owned/rented. *
Date of Loss Location Brief description Amount Paid ($)
Have there been any insurance claims at THIS location in the last five years? **
Have there been any insurance claims at THIS location in the last five years? *
- Yes
- No
Please provide details about any insurance claim(s) at THIS location in the last five years. **
Please provide details about any insurance claim(s) at THIS location in the last five years. *
Date of Loss Brief description Amount Paid ($)
Would you like a flood insurance proposal for your home?
Would you like a flood insurance proposal for your home?
- Yes
- No
Flood Insurance Information
Has the home been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Has the home been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
- Yes
- No
- Not sure
Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)
Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)
- Basement
- Basement, but elevated
- Garage
- Garage, but elevated
- Outside
- Outside, but elevated
- Other
Please describe where the machinery for this residence is located.
Please describe where the machinery for this residence is located.
Where is your personal property kept at this location?
Where is your personal property kept at this location?
Please describe where the personal property is kept at this location.
Please describe where the personal property is kept at this location.
Does this home have flood vents?
Does this home have flood vents?
- Yes
- No
Do you have a flood insurance policy in place today?
Do you have a flood insurance policy in place today?
- Yes
- No
Please upload a copy of your Flood insurance policy, if available.
Please upload a copy of your Flood insurance policy, if available.
Accepted file types: pdf, jpeg, jpg, png, Max. file size: 10 MB.
Have you been paid over $5,000 on any flood claims in the last 10 years?
Have you been paid over $5,000 on any flood claims in the last 10 years?
- Yes
- No
Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.
Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.
Is your policy being cancelled or non-renewed?
Is your policy being cancelled or non-renewed?
- Yes
- No
Please tell us your insurer's reason for cancelling or non-renewing your policy.
Please tell us your insurer's reason for cancelling or non-renewing your policy.
Do you have an elevation certificate for this property? **
Do you have an elevation certificate for this property? *
- Yes
- No
Please upload a copy of the elevation certificate
Please upload a copy of the elevation certificate
Accepted file types: pdf, jpg, jpeg, png, Max. file size: 10 MB.
Have there been any flood insurance claims at this residence?
Have there been any flood insurance claims at this residence?
- Yes
- No
Please provide details about the flood insurance claims at this residence.
Please provide details about the flood insurance claims at this residence.
Date of Loss Brief description Amount Paid ($)
Additional Coverage Options
Other insurance services
By the way, we also handle several other products and services at our firm. Please let us know if you are interested in exploring any of them by checking the boxes below. (Please check all that apply)
- Automobile
- Rental Property
- Tenants
- Boat
- Recreational Vehicle (RV)
- Motorcycle
- Jewelry and other valuables
- Umbrella
- Business
- Health
- Life
- Long Term Care
- Disability
- Financial Planning
- None
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, home inspection, etc...)
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, home inspection, 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.
How did you hear about us?
How did you hear about us?
Please share who referred you to us.
Please share who referred you to us.
Can you share what you typed into Google?
Can you share what you typed into Google?
Please let us know how you heard about us.
Please let us know how you heard about us.
<font size="2" color="gray">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.*
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.
I agree *

Katie Rogalewicz

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Principal/Beneficial Owner Name/Trustee(s)	Relationship to you

Name	Occupation

Date of Loss	Location	Brief description	Amount Paid ($)

Date of Loss	Brief description	Amount Paid ($)

Homeowners Insurance Florida Form - Valiant Group

Legal Entity Information

Residence Information

Solar Panel Information

Flood Insurance Information

Additional Coverage Options

Documents and Comments

Katie Rogalewicz

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