What is your first name? *
What is your last name? *
What is your preferred phone number? *
What is your email address? *
What is your occupation and employer name?
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?
Please enter their occupation and employer name:
Please enter their date of birth.
MM slash DD slash YYYY
Customize Your Insurance Quote
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)?
Homeowners
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 closing date?
MM slash DD slash YYYY
When do you need this coverage to start?
MM slash DD slash YYYY
Please select the intended occupancy of the property you are purchasing.
What is the intended occupancy of the home you are purchasing?
Please select the occupancy of this home.
What is the intended occupancy of the home you are purchasing?
Please enter your current home address.
Please enter 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 do a major renovation to this home shortly after you purchase it?
What is the approximate budget for the renovation?
How long will the renovation take?
Please provide a brief description of the renovation plans.
Please select the frequency of rentals for this home.
Will there be a mortgage?
What is the name of the bank 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 Trust, LLC or Limited Partnership 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?
Please provide details about the way(s) this entity generates income.
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.
Home Details
Is there an alarm system in this home?
Select the components of your alarm system.
Please select the risk mitigation features of this property.
Enter the other risk mitigation feature(s) in this home.
Has a 4-point inspection be done on this home?
Please upload a copy of the 4-point inspection, if available.
Has a windstorm/wind mitigation inspection be 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? (YYYY)
How many stories does this home have?
What is the age of the roof? (YYYY)
Please select your roof type.
Please provide a brief description of your roof type.
Please select the construction type of your home.
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 year did you update the electrical? (YYYY)
What year did you update the plumbing? (YYYY)
What year did you update the heating? (YYYY)
What year did you update the windows? (YYYY)
What year did you update the roof? (YYYY)
What type of foundation does your home have?
Please select the other structures on this property.
Enter a brief description of the other structure(s) on this property.
Is there an attached garage?
How many car bays does the attached garage have?
Does this home include solar panels? *
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)
What breed of dog do you have?
Please select the type of wood burning stove you have:
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 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 for any residence 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.
Condominium / Cooperative
Please enter the address of the condo/co-op you would like an insurance proposal for (Include apartment number, if applicable).
Are you purchasing this condo/co-op?
What is the purchase price?
What is the expected closing date for this new condo / coop purchase?
MM slash DD slash YYYY
What is your desired start date for this coverage?
MM slash DD slash YYYY
Is this a Condominium or Cooperative?
What is the intended occupancy of this condominium/cooperative?
Please describe the intended occupancy of this condominium/cooperative?
What is the occupancy of this condominium/cooperative?
Please describe the intended occupancy of this condominium/cooperative?
Please select the months this unit will be occupied. (Select all that apply)
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?
Please select the frequency of rentals for this Condo/Co-op.
Please describe the intended occupancy of this condominium/cooperative?
Will you renovate the condo/co-op prior to moving in?
What is the budget for the renovation?
How long will the renovations take to complete?
How long with the renovations take to complete?
Will there be a mortgage?
What is the name of the bank 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 this condominium or cooperative owned by a trust, LLC or other entity?
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:
Is the mailing address for the legal entity the same as the location address for this proposal?
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?
Please provide details about how this entity generates income.
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.
Condominium/Cooperative Details
Is there an alarm system in this condominium/cooperative?
Select the components of your alarm system.
What other components does your alarm system have?
What is the square footage of this unit? (Under air)
What year was this condominium/cooperative built?
Does this unit have fire sprinklers?
How many stories does this building have?
On which floor is this unit located?
Has a 4-point inspection be done on this condominium/cooperative?
Please upload a copy of the 4-point inspection, if available.
Do you have a windstorm mitigation inspection certificate for this condominium/cooperative or for the association?
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 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.
Select the systems in your condo/co-op that have been updated within the last 10 years.
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 plumbing?
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 windows?
What would it cost to replace your personal belongings at this location? (I.e. Clothing, furniture, rugs, electronics, etc...)
Would you like to include mold/fungi coverage in your proposal?
Would you like a flood insurance proposal for your Condo/Co-op?
Flood Insurance Information
Has the condo/co-op been substantially improved since it was built? (Over 50% of the market value was spent to renovate)
Where is the machinery that services this unit 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 condo/co-op have flood vents?
Is there a flood insurance policy in place today?
Please upload a copy of the Flood insurance policy, if available.
Is the flood policy being cancelled or non-renewed?
Please share the insurer's reason for cancelling or non-renewing your policy.
Do you have an elevation certificate for the building from the condo/co-op association?
Please upload a copy of the elevation certificate
Have there been any flood insurance claims in this unit?
Have you been paid over $5,000 on any flood claims in the last 10 years?
Please provide details about the flood insurance claims at this residence.
Renters
Please enter the address of the location you are renting.
What type of property is this?
What is the occupancy of this property?
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?
Valuable Articles
Please select the types of valuable articles you would like an insurance proposal for?
Tell us about your jewelry collection.
Do you have any recent appraisals for your jewelry? (3 years old or newer)
Feel free to upload your appraisals here.
Tell us about your fine art collection.
Do you have any recent appraisals for your fine art? (5 years old or newer)
Feel free to upload your appraisals here.
Tell us about your wine collection.
Tell us about your firearms collection.
Tell us about your musical instruments collection.
Tell us about your other collections.
Automobile
Please enter your home address.
Is this residence owned or rented?
Is this the address where your vehicle(s) are kept?
Do you currently have automobile insurance in force?
Please list your vehicles:
What is the state of registration for your vehicle(s)?
Please enter drivers license information for all drivers in the household.
How are your vehicles used?
Please enter the vehicle identification number(s):
Are any of your vehicles owned by a business, trust, LLC or Limited Partnership?
Please provide details about vehicle ownership.
Any drivers away at school?
Please list the driver(s) away at school.
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 collision coverage on your full coverage vehicle(s)?
Have there been any moving violations for any driver in the past five years?
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?
Personal Excess Liability / Umbrella
Please select the excess liability/personal umbrella limit you would like a quote for.
Please enter the excess liability/umbrella limit you would like a quote for.
Select the types of recreational vehicles you own or lease.
Please list any watercraft you own or lease.
Please list any motorcycles you own or lease.
Please list any ATVs you own or lease.
Please list any snowmobiles 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 other vehicle types you own or lease.
Please check any of the following other liability exposures that apply.
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.) *
Please select the type(s) of insurance claim(s) you have had in the past five years. *
Please provide details about the Homeowners insurance claim(s). *
Please provide details about the Automobile insurance claim(s). *
Please provide details about the Valuable Articles insurance claim(s). *
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? *
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. (I.e. Current policy declarations pages, appraisals, etc...)
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.
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.
