Insured 1 - First Name* What is your first name? *
Insured 1 - 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? *
Occupation & Employer What is your occupation and employer name?
Insured 1 Date of Birth* What is your date of birth? *
MM slash DD slash YYYY
Insured 1 - Marital Status What is your marital status?
Single Married Domestic Partnership Engaged Divorced Widowed
Spouse - Full Name What is your spouse's full name?
Domestic Partner - Full Name What is your partner's full name?
Fiancé - Full Name What is your fiancé's full name?
Other Insured's Occupation & Employer Please enter their occupation and employer name:
Insured 2 - Date of Birth Please enter their date of birth.
MM slash DD slash YYYY
Customize Your Insurance Quote Selected Quotes* You have the ability to customize this form by unchecking the boxes next to the coverages you do not wish to receive quotes for.
What is/are the name(s) of your current insurance carrier(s)? What is/are the name(s) of your current insurance carrier(s)?
Homeowners Property Address Please enter the address of the location you would like an insurance proposal for.
New Purchase? Are you in the process of purchasing this home?
Purchase Price What is the purchase price?
New Home Purchase Closing Date What is the closing date?
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
New Purchase Occupancy Please select the intended occupancy of the property you are purchasing.
New Purchase Occupancy Other What is the intended occupancy of the home you are purchasing?
Owned Home Occupancy Please select the occupancy of this home.
Owned Home Occupancy Other What is the intended occupancy of the home you are purchasing?
Current Home Address Please enter your current home address.
Primary Home Address Please enter your primary home address.
New Purchase - 3 Yrs at Current Residence Have you lived at your current address for three or more years?
Owned Home - 3 Yrs at Current Residence Have you lived at your primary home address for three or more years?
New Purchase - Previous Home Address Please provide the address where you lived prior to your current address?
Owned Home - Previous Home Address Please provide the address where you lived prior to your current address?
Major Renovation Will you do a major renovation to this home shortly after you purchase it?
Renovation Budget What is the approximate budget for the renovation?
Renovation Time Frame How long will the renovation take?
Please provide a brief description of the renovation plans. Please provide a brief description of the 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 providing the mortgage? What is the name of the bank 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?
What is the email address for your contact at the bank? What is the email address for your contact at the bank?
Will the insurance premium be escrowed? Will the insurance premium be escrowed?
Is there a mortgage? Is there a mortgage?
Please enter the bank name, if convenient. Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. Please enter the bank address, if convenient.
Please enter the loan number, if convenient. Please enter the loan number, if convenient.
Is the insurance premium being escrowed? Is the insurance premium being escrowed?
Trust or LLC Is there a Trust, LLC or Limited Partnership involved in the ownership of this property?
Legal Entity Information Legal Entity Name What is the name of the legal entity?
Legal Entity Type What type of legal entity is it?
Limited Liability Company (LLC) Trust Limited Liability Partnership (LLP) Family Limited Partnership (FLP) Other
Legal Entity Type Other Please enter the type of legal entity:
Legal Entity Mailing Address What is the mailing address for the legal entity?
Legal Entity Owned Assets Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Legal Entity Beneficial Owners Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
Legal Entity Purpose What is the purpose or intent of the entity?
Legal Entity Income Generation? 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?
Legal Entity Income Generation Details Please provide details about the income generation and business conducted by this entity.
Legal Entity Income Generation Other Does the entity generate income in any other ways?
Please provide details about the way(s) this entity generates income. Please provide details about the way(s) this entity generates income.
Legal Entity Asset Ownership Other Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Legal Entity Other Assets List Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Legal Entity Employees Does the entity have any employees?
Legal Entity Employee Names and Occupations Please list the name and occupation for each of the employees:
Legal Entity Payroll Info Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Legal Entity Insurance Policies Does the entity maintain any other insurance policies?
Legal Entity Other Insurance Coverage Info Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Home Details Alarm System Is there an alarm system in this home?
Alarm System Components Select the components of your alarm system.
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.
Four Point Inspection Home? Has a 4-point inspection be done on this home?
Four Point Inspection Home Upload Please upload a copy of the 4-point inspection, if available.
Wind Mitigation Inspection? Has a windstorm/wind mitigation inspection be done on this home?
Windstorm Mitigation Certificate Upload Please upload a copy of the windstorm/wind mitigation certificate, if available.
Approximate Square Footage What is the approximate square footage of this home?
Year Built What year was this home built? (YYYY)
How many stories does this home have? How many stories does this home have?
What is the age of the roof? (YYYY) What is the age of the roof? (YYYY)
Please select your roof type. Please select your roof type.
Please provide a brief description of your roof type. Please provide a brief description of your roof type.
Please select the construction type of your home. Please select the construction type of your home.
System Updates Select the features of your home that have been updated within the last 10 years.
What other updates have you done to your home? What other updates have you done to your home?
What year did you update the electrical? (YYYY) What year did you update the electrical? (YYYY)
What year did you update the plumbing? (YYYY) What year did you update the plumbing? (YYYY)
What year did you update the heating? (YYYY) What year did you update the heating? (YYYY)
What year did you update the windows? (YYYY) What year did you update the windows? (YYYY)
What year did you update the roof? (YYYY) What year did you update the roof? (YYYY)
What type of foundation does your home have? What type of foundation does your home have?
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.
Is there an attached garage? Is there an attached garage?
Attached garage car bays? How many car bays does the attached garage have?
Does this home include solar panels? ** Does this home include solar panels? *
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 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)
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:
Sink Hole Insurance Proposal? Would you like to include sink hole coverage in your proposal?
Mold/Fungi Insurance Proposal? Would you like to include mold/fungi coverage in your proposal?
Would you like a flood insurance proposal for your home? Would you like a flood insurance proposal for your home?
Flood Insurance Information Substantially Improved? Has the home been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Machinery Location Where is the machinery that services this residence located? (Air conditioning, Furnace, Boiler, etc...)
Machinery Location Other Please describe where the machinery for this residence is located.
Contents Location Where is your personal property kept at this location?
Ground level and above Basement and above Elevated floor and above Other
Contents Location Other Please describe where the personal property is kept at this location.
Flood Vents Does this home have flood vents?
Flood Insurance Policy Do you have a flood insurance policy in place today?
Flood Policy PDF Please upload a copy of your Flood insurance policy, if available.
Claims Have you been paid over $5,000 on any flood claims for any residence in the last 10 years?
Claims Description Please tell us about the claim(s), including amount paid by your insurer and a brief description of what happened.
Policy Cancellation Is your policy being cancelled or non-renewed?
Policy Cancellation Description Please tell us your insurer's reason for cancelling or non-renewing your policy.
Elevation Certificate Do you have an elevation certificate for this property?
Elevation Certificate File Upload Please upload a copy of the elevation certificate
Flood claims? Have there been any flood insurance claims at this residence?
Flood claim details Please provide details about the flood insurance claims at this residence.
Condominium / Cooperative Condo / Co-op Address Please enter the address of the condo/co-op you would like an insurance proposal for (Include apartment number, if applicable).
New Condo/Co-op Purchase? Are you purchasing this condo/co-op?
Condo/Co-op Purchase Price? What is the purchase price?
New Purchase Condo / Coop Closing Date What is the expected closing date for this new condo / coop purchase?
MM slash DD slash YYYY
Owned Condo / Coop Effective Date What is your desired start date for this coverage?
MM slash DD slash YYYY
Is this a Condominium or Cooperative? Is this a Condominium or Cooperative?
New Purchase - Condo/Co-op Occupancy What is the intended occupancy of this condominium/cooperative?
New Purchase Condo/Coop Other Occupancy Please describe the intended occupancy of this condominium/cooperative?
Owned Condo/Co-op Occupancy What is the occupancy of this condominium/cooperative?
Owned Condo/Coop Other Occupancy Please describe the intended occupancy of this condominium/cooperative?
Months Occupied? Please select the months this unit will be occupied. (Select all that apply)
Condo/Coop - Current Home Address What is your current home address?
Condo/Coop - Primary Home Address What is your primary home address?
New Condo/Coop Purchase - 3 Yrs at Current Residence Have you lived at your current address for three or more years?
Owned Condo/Coop - 3 Yrs at Current Residence Have you lived at your primary home address for three or more years?
New Condo/Coop Purchase - Previous Home Address Please provide the address where you lived prior to your current address?
Owned Condo/Coop - Previous Home Address Please provide the address where you lived prior to your current address?
Please select the frequency of rentals for this Condo/Co-op. Please select the frequency of rentals for this Condo/Co-op.
Please describe the intended occupancy of this condominium/cooperative? Please describe the intended occupancy of this condominium/cooperative?
Condo/Co-op Renovation Will you renovate the condo/co-op prior to moving in?
Condo/Co-op Renovation Budget What is the budget for the renovation?
Condo/Co-op Renovation Time Frame How long will the renovations take to complete?
How long with the renovations take to complete? How long with the renovations take to complete?
Condo / Co-op New Purchase Mortgage Will there be a mortgage?
What is the name of the bank providing the mortgage? What is the name of the bank 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?
What is the email address for your contact at the bank? What is the email address for your contact at the bank?
Will the insurance premium be escrowed? Will the insurance premium be escrowed?
Condo/Co-op Mortgage Is there a mortgage?
Please enter the bank name, if convenient. Please enter the bank name, if convenient. (Ex. Bank of America NA, ISAOA ATIMA)
Please enter the bank address, if convenient. Please enter the bank address, if convenient.
Please enter the loan number, if convenient. Please enter the loan number, if convenient.
Is the insurance premium being escrowed? Is the insurance premium being escrowed?
Condo/Co-op Trust or LLC Is this condominium or cooperative owned by a trust, LLC or other entity?
Legal Entity Information Legal Entity Name What is the name of the legal entity?
Legal Entity Type What type of legal entity is it?
Limited Liability Company (LLC) Trust Limited Liability Partnership (LLP) Family Limited Partnership (FLP) Other
Legal Entity Type Other Please enter the type of legal entity:
Legal Entity Mailing Address Match? Is the mailing address for the legal entity the same as the location address for this proposal?
Legal Entity Mailing Address What is the mailing address for the legal entity?
Legal Entity Owned Assets Please provide a description of the asset(s) owned by this entity. (Address, personal property, etc...)
Legal Entity Beneficial Owners Please provide the principal/beneficial owner(s)/trustee name(s) and their relationship to you.
Legal Entity Purpose What is the purpose or intent of the entity?
Legal Entity Income Generation? 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?
Legal Entity Income Generation Details Please provide details about the income generation and business conducted by this entity.
Legal Entity Income Generation Other Does the entity generate income in any other ways?
Legal Entity Income Generation Other Details Please provide details about how this entity generates income.
Legal Entity Asset Ownership Other Does the entity own any other real estate, vehicles, watercraft or other tangible assets?
Legal Entity Other Assets List Please list the other assets this entity owns: (I.e. Address, vehicles, watercraft, etc...)
Legal Entity Employees Does the entity have any employees?
Legal Entity Employee Names and Occupations Please list the name and occupation for each of the employees:
Legal Entity Payroll Info Please describe how the employees are paid. (Ie. Frequency, Payroll Service, etc...)
Legal Entity Insurance Policies Does the entity maintain any other insurance policies?
Legal Entity Other Insurance Coverage Info Please provide the insurance company name(s), coverage type and coverage limits for the other policies.
Condominium/Cooperative Details Condo/Co-op Alarm System Is there an alarm system in this condominium/cooperative?
Condo/Co-op Alarm System Components Select the components of your alarm system.
Condo/Co-op Alarm Components Other What other components does your alarm system have?
Unit Square Footage? What is the square footage of this unit? (Under air)
Condo/Co-op Year Built What year was this condominium/cooperative built?
Unit Fire Sprinklers? Does this unit have fire sprinklers?
Condo/Co-op Total Stories? How many stories does this building have?
Unit Floor Number? On which floor is this unit located?
Four Point Inspection Condo/Coop? Has a 4-point inspection be done on this condominium/cooperative?
Four Point Inspection Condo/Coop Upload Please upload a copy of the 4-point inspection, if available.
Wind Mitigation Inspection? Do you have a windstorm mitigation inspection certificate for this condominium/cooperative or for the association?
Windstorm Mitigation Certificate Upload Please upload a copy of the windstorm/wind mitigation certificate, if available.
Do you have any information that will assist us in estimating the replacement cost of the improvements and betterments? Do you have any information that will assist us in estimating the replacement cost of the improvements and betterments in this unit? (I.e. Recent renovation costs, ball park construction cost to rebuild the unit, any unique features, etc...)
Please share the information you have about the replacement cost of the improvements and betterments in this unit. Please share the information you have about the replacement cost of the improvements and betterments in this unit.
Select the systems in your condo/co-op that have been updated within the last 10 years. Select the systems in your condo/co-op that have been updated within the last 10 years.
What other systems have been updated? What other systems have been updated?
What year did you update the condo/co-op's electrical? What year did you update the condo/co-op's electrical?
What year did you update the condo/co-op's plumbing? What year did you update the condo/co-op's plumbing?
What year did you update the condo/co-op's heating? What year did you update the condo/co-op's heating?
What year did you update the condo/co-op's roof? What year did you update the condo/co-op's roof?
What year did you update the condo/co-op's windows? What year did you update the condo/co-op's windows?
What would it cost to replace your personal belongings at this location? (I.e. Clothing, furniture, rugs, electronics, etc...) What would it cost to replace your personal belongings at this location? (I.e. Clothing, furniture, rugs, electronics, etc...)
Mold/Fungi Insurance Proposal? Would you like to include mold/fungi coverage in your proposal?
Would you like a flood insurance proposal for your Condo/Co-op? Would you like a flood insurance proposal for your Condo/Co-op?
Flood Insurance Information Substantially Improved? Has the condo/co-op been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Machinery Location Where is the machinery that services this unit located? (Air conditioning, Furnace, Boiler, etc...)
Machinery Location Other Please describe where the machinery for this residence is located.
Contents Location Where is your personal property kept at this location?
Ground level and above Basement and above Elevated floor and above Other
Contents Location Other Please describe where the personal property is kept at this location.
Flood Vents Does this condo/co-op have flood vents?
Flood Insurance Policy Is there a flood insurance policy in place today?
Flood Policy PDF Please upload a copy of the Flood insurance policy, if available.
Policy Cancellation Is the flood policy being cancelled or non-renewed?
Policy Cancellation Description Please share the insurer's reason for cancelling or non-renewing your policy.
Elevation Certificate Do you have an elevation certificate for the building from the condo/co-op association?
Elevation Certificate File Upload Please upload a copy of the elevation certificate
Flood claims? Have there been any flood insurance claims in this unit?
Claims Payments Over $5,000 Have you been paid over $5,000 on any flood claims in the last 10 years?
Flood claim details Please provide details about the flood insurance claims at this residence.
Renters Please enter the address of the location you are renting. Please enter the address of the location you are renting.
What type of property is this? What type of property is this?
What is the occupancy of this property? What is the occupancy of this property?
What is the approximate value of the personal belongings you will have at this residence? What is the approximate value of the personal belongings you will have at this residence? (Personal belongings include furniture, clothing, electronics, kitchen items, linens, and other possessions that you own.)
Would you like a flood insurance proposal for your rental? Would you like a flood insurance proposal for your rental?
Valuable Articles Valuables Categories Please select the types of valuable articles you would like an insurance proposal for?
Jewelry Collection Tell us about your jewelry collection.
Jewelry Appraisals? Do you have any recent appraisals for your jewelry? (3 years old or newer)
Jewelry Appraisal Upload Feel free to upload your appraisals here.
Fine Art Collection Tell us about your fine art collection.
Fine Art Appraisals? Do you have any recent appraisals for your fine art? (5 years old or newer)
Fine Art Appraisal Upload Feel free to upload your appraisals here.
Wine Collection Tell us about your wine collection.
Firearms Collection Tell us about your firearms collection.
Musical Instruments Collection Tell us about your musical instruments collection.
Other Collection Tell us about your other collections.
Automobile Please enter your home address. Please enter your home address.
Is this residence owned or rented? Is this residence owned or rented?
Is this the address where your vehicle(s) are kept? Is this the address where your vehicle(s) are kept?
Do you currently have automobile insurance in force? Do you currently have automobile insurance in force?
Please list your vehicles: Please list your vehicles:
What is the state of registration for your vehicle(s)? What is the state of registration for your vehicle(s)?
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific
Please enter drivers license information for all drivers in the household. Please enter drivers license information for all drivers in the household.
How are your vehicles used? How are your vehicles used?
Please enter the vehicle identification number(s): Please enter the vehicle identification number(s):
Are any of your vehicles owned by a business, trust, LLC or Limited Partnership? Are any of your vehicles owned by a business, trust, LLC or Limited Partnership?
Please provide details about vehicle ownership. Please provide details about vehicle ownership.
Any drivers away at school? Any drivers away at school?
Please list the driver(s) away at school. Please list the driver(s) away at school.
What type of coverage would you like for your automobile insurance? What type of coverage would you like for your automobile insurance?
What deductible option would you like for comprehensive coverage on your full coverage vehicle(s)? What deductible option would you like for comprehensive coverage on your full coverage vehicle(s)?
$100 $200 $300 $500 $1,000 $2,000 $2,500 $3,000 $5,000 $10,000 Not sure
What deductible option would you like for collision coverage on your full coverage vehicle(s)? What deductible option would you like for collision coverage on your full coverage vehicle(s)?
$100 $200 $300 $500 $1,000 $2,000 $2,500 $3,000 $5,000 $10,000 Not sure
Driver Violations? Have there been any moving violations for any driver in the past five years?
Moving Violation Description Please list the driver, date, and a brief description of the moving violation(s) below.
Are any drivers in your household required to have an SR-22? Are any drivers in your household required to have an SR-22?
Personal Excess Liability / Umbrella Umbrella quote limit Please select the excess liability/personal umbrella limit you would like a quote for.
$1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 $6,000,000 $7,000,000 $8,000,000 $9,000,000 $10,000,000 $11,000,000 $12,000,000 $13,000,000 $14,000,000 $15,000,000 $16,000,000 $17,000,000 $18,000,000 $19,000,000 $20,000,000 Other Not sure
Other umbrella quote limit Please enter the excess liability/umbrella limit you would like a quote for.
Select the types of recreational vehicles you own or lease. Select the types of recreational vehicles you own or lease.
Please list any watercraft you own or lease. Please list any watercraft you own or lease.
Please list any motorcycles you own or lease. Please list any motorcycles you own or lease.
Please list any ATVs you own or lease. Please list any ATVs you own or lease.
Please list any snowmobiles you own or lease. Please list any snowmobiles you own or lease.
Please list any jet skis you own or lease. Please list any jet skis you own or lease.
Please list any RV/Mobile homes you own or lease. Please list any RV/Mobile homes you own or lease.
Please list any any other vehicle types you own or lease. Please list any other vehicle types you own or lease.
Other Liability Exposures Please check any of the following other liability exposures that apply.
Please provide a brief description of your other liability risks. Please provide a brief description of your other liability risks.
Insurance Claims Have you had any insurance claims in the last five years? (Please include claims from previously owned/rented locations from the past five years.) ** Have you had any insurance claims in the last five years? (Please include claims from previously owned/rented locations from the past five years.) *
Claim type* Please select the type(s) of insurance claim(s) you have had in the past five years. *
Homeowners claim details* Please provide details about the Homeowners insurance claim(s). *
Automobile claim details* Please provide details about the Automobile insurance claim(s). *
Valuable articles claim details* Please provide details about the Valuable Articles insurance claim(s). *
Other claim details* Please provide details about the other insurance claim(s). *
Have there been any insurance claims at the location(s) you're requesting a proposal for in the last five years? ** Have there been any insurance claims at the location(s) you're requesting a proposal for in the last five years? *
Please provide details about any insurance claim(s) at the location(s) you're requesting a proposal for. ** Please provide details about any insurance claims at the location(s) you're requesting a proposal for. *
Documents and Comments Please use this field to upload any relevant insurance documents. Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, appraisals, 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.
Please share what you typed into Google. Please share what you typed into Google.
Please share how you heard about us. Please share how you heard about us.
Consent* 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 *