New Policy – Homeowners Basic Form

What is your first name?

What is your last name?

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What is your full name?

What is your preferred phone number?

Email

Please enter your email.

Occupation & Employer

What is your occupation and employer name?

Please enter your Date of Birth

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Date of Birth

Please enter your Date of Birth (MM/DD/YY):

Will anyone else be named on this quote?

Yes
No

Other Insured's Name

Please enter their name:

Other Insured's Occupation & Employer

Please enter their occupation and employer name:

Please enter their Date of Birth

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Other Insured's Date of Birth

Please enter their Date of Birth (MM/DD/YY):

Please enter the address of the location you would like a proposal for.

Street Address Address Line 2 City State ZIP Code

New Purchase?

Are you in the process of purchasing this home?

Yes
No

Purchase Price

What is the purchase price?

What is the Closing Date?

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Closing Date

What is the closing date? (MM/DD/YY)

When do you need this coverage to start?

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Effective date

When do you need this coverage to start? (MM/DD/YY)

Major Renovation

Will you do a major renovation to this home shortly after you purchase it?

Yes
No

Major Renovation Current Home

Do you have plans to do a major renovation at this home?

Yes
No

Renovation Budget

What is the approximate budget for the renovation?

Renovation Time Frame

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

Occupancy

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

Occupancy other

What is the occupancy of this home?

What is your current home address?

Street Address Address Line 2 City State ZIP Code

Please enter your primary/current address.

Street Address Address Line 2 City State ZIP Code

Will there be a mortgage?

Yes
No

What is the name of the bank providing the mortgage?

What is the name of your current insurance company?

Is there a mortgage?

Yes
No

Please enter the bank name, if convenient.

Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)

Trust or LLC

Is there a Trust, LLC or Limited Partnership involved in the ownership of this property?

Yes
No

Trust or LLC Name

Please enter the name of the Trust, LLC or Limited Partnership:

Alarm System

Is there an alarm system in this home?

Yes
No

Alarm System Components

Select the components of your alarm system.

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

Alarm

What other alarm components does your system have?

Risk Mitigation Features

Please select the risk mitigation features of this property.

Risk Mitigation Other

Enter the other risk mitigation feature(s) in this home.

Approximate Square Footage

What is the approximate square footage of this home?

Year Built

What year was this home built? (YYYY)

What is the age of your roof? (YYYY)

Please select your roof type:

Please provide a description of your roof type:

Construction Quality Selection

Please select the word that most accurately describes this home's quality of construction.

System/features Updates

Select the features of your home that have been updated within the last 10 years.

Electrical
Plumbing
Heating
Roof
Windows
None
Other

System/features updates other

What other updates have you done to your home?

What year did you update the electrical?

What year did you update the plumbing?

What year did you update the heating?

What year did you update the roof?

What year did you update the windows?

Property Structures

Please select the other structures on this property.

Other Property Structures

Enter a brief description of the other structure(s) on this property.

Would you like a flood insurance proposal for your home?

Yes
No

Documents and Comments

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)

Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, home inspection, appraisals, etc...)

Drop files here or

Accepted file types: jpg, gif, tiff, png, pdf, Max. file size: 128 MB, Max. files: 5.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share 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. 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. *</font>*

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 *

Homeowners Insurance Basic Form

Documents and Comments

Michele Bolling

RiskRevu^TM Newsletter

Contact

Homeowners Insurance Basic Form

Documents and Comments

Michele Bolling

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter