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? *
Single Married Domestic Partnership Engaged Divorced Widowed
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.
Are you in the process of purchasing this home? Are you in the process of purchasing this home?
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.
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.
What is the occupancy of this home? What is the occupancy of this home?
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What is your current home address? What is your current home address?
What is your primary 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 current address for three or more years?
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?
Please provide the address where you lived prior to your current address? Please provide the address where you lived prior to your current address?
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? Will you renovate this home after you purchase it?
Do you have plans to do a renovation at this home? Do you have plans to do a renovation at this home?
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?
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.
Will there be a mortgage? Will there be a mortgage?
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?
Current Mortgage? Is there a mortgage?
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.
Loan Number Current Insurance Please enter the loan number, if convenient.
Premium Escrowed Current Insurance Is the insurance premium being escrowed?
Second mortgage/Home Equity Loan 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? 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 is the name of the legal entity?
What type of legal entity is it? What type of legal entity is it?
Limited Liability Company (LLC) Trust Limited Liability Partnership (LLP) Family Limited Partnership (FLP) Other
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?
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.
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?
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?
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?
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?
Please list the name and occupation for each of the employees: Please list the name and occupation for each of the employees:
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?
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?
Select the components of your alarm system. Select the components of your alarm system.
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.
Please select the risk mitigation features of this property. Please select the risk mitigation features of this property.
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? *
Please upload a copy of the 4-point inspection, if available. Please upload a copy of the 4-point inspection, if available.
Has a windstorm/wind mitigation inspection been done on this home? ** Has a windstorm/wind mitigation inspection been done on this home? *
Please upload a copy of the windstorm/wind mitigation certificate, if available. Please upload a copy of the windstorm/wind mitigation certificate, if available.
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:
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? *
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)
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)
Do you own or lease the solar panels? Do you own or lease the solar panels?
Are you responsible for insuring the panels? Are you responsible for insuring the panels?
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.
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.
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?
How many water heaters are in use at this residence? ** How many water heaters are in use at this residence? *
1 2 3 4
Water Heater Information - #1 What year was this water heater installed? ** What year was this water heater installed? *
What type of water heater is this? ** What type of water heater is this? *
Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). ** Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). *
Water Heater Information - #2 What year was this water heater installed? * 2* What year was this water heater installed? *
What type of water heater is this? * 2* What type of water heater is this? *
Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). * 2* Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). *
Water Heater Information - #3 What year was this water heater installed? * 3* What year was this water heater installed? *
What type of water heater is this? * 3* What type of water heater is this? *
Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). * 3* Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). *
Water Heater Information - #4 What year was this water heater installed? * 4* What year was this water heater installed? *
What type of water heater is this? * 4* What type of water heater is this? *
Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). * 4* Where is the water heater located? (I.e. Garage, 1st floor closet, 2nd floor closet, etc). *
What type of heating system does the home have? What type of heating system does the home have?
Oil Gas Electric Other
Please describe the heating system. Please describe the heating system.
Where is the oil tank located? Where is the oil tank located?
What type of foundation does the home have? What type of foundation does the home have?
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.
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?
Is there a diving board or slide attached to the pool? Is there a diving board or slide attached to the pool?
Is there an attached garage? Is there an attached garage?
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)
Is there safety netting around the trampoline? Is there safety netting around the trampoline?
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:
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.
Please select the types of valuable property you own. Please select the types of valuable property you own.
Please tell us about your jewelry. Please tell us about your jewelry.
Please tell us about your fine art. Please tell us about your fine art.
Please tell us about your other valuable items. Please tell us about your other valuable items.
Would you like to include sink hole coverage in your proposal? Would you like to include sink hole coverage in your proposal?
Would you like to include mold/fungi coverage in your proposal? Would you like to include mold/fungi coverage in your proposal?
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? *
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. *
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? *
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. *
Would you like a flood insurance proposal for your home? 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) 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...) Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)
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?
Ground level and above Basement and above Elevated floor and above Other
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?
Do you have a flood insurance policy in place today? Do you have a flood insurance policy in place today?
Please upload a copy of your Flood insurance policy, if available. 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? 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. 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?
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? *
Please upload a copy of the elevation certificate Please upload a copy of the elevation certificate
Have there been any flood insurance claims at this residence? Have there been any flood insurance claims at this residence?
Please provide details about the 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 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. Please enter any additional remarks in the space below.
How did you hear about us? How did you hear about us?
Current customer Referred by... Google search Agency's website Email newsletter Facebook Instagram Twitter Other
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.
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.
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