Homeowners/Condo, Co-Op, RentersApplication FormPlease complete this form and we will contact you with a quotePersonal Information:Last NameFirst NameSocial Security NumberBirth Date MM slash DD slash YYYY Street AddressCityStateZipPhoneEmail Property Information:Property Street AddressCityStateZip CodeDwelling TypeHomeCondoCo-opRentersNumber of BedroomsNumber of BathroomsNumber of FireplacesHow many porches or decks are thereWhat year was it builtWhat date was the property purchasedWhat is the construction type?Wood FrameBrickHow many stories in it?If two stories, what is the ground floor square footage?Total square footage?BasementNoneFullPartialWhat is the Distance to Body of WaterGarage DescriptionNone1-2 Car Built in1-2 CarWhat type of roof coveringWas the roof updated Yes NoIf yes, what yearDoes the home have a pool? Yes NoIf yes, is it fenced? Yes NoIf there is a pool, is there a diving board Yes NoIf there is a pool, is there a slide? Yes NoWhat is the distance of fire hydrant?Is there a smoke alarm? Yes NoAre there fire extinguishers? Yes NoAre there deadbolts? Yes NoIs the electrical updated? Yes NoAre there circuit breakers? Yes NoDoes the electrical circuit box have copper wiring? Yes NoHow old is the heating/air conditioningWhat is the heating system?OilGasIf Oil, where is the tank locatedCentral A/C Yes NoHas the plumbing been updated? Yes NoIs the plumbing copper? Yes NoDoes the building have interior automatic fire sprinklers? Yes NoIs there a theft alarm? Yes NoIs there the fire district? Yes NoAre there dogs on the property? Yes NoIf yes, how many and what is the breed of each dog?Are there dogs on the property? Yes NoIf yes, who many and what is the description of each?Current Coverage InformationCurrent Insurance CompanyExpiration Date MM slash DD slash YYYY Were there any losses or claims in the last 5 years Yes NoIf yes, what is the date, amount paid and description of each loss or claimDesired Current Coverage Information:Dwelling Amount-Coverage AOther Structures-Coverage B APersonal Property-Coverage CLoss of Use-Coverage DPremise Liability-Coverage EPremise Liability-Coverage E300000500000Policy DeductiblePremise Liability-Coverage E50010001500Questions or CommentsBest Time to Contact YouPlease let us know the best time to call and discuss your quote Morning Afternoon Evening AnytimeOr Specify OtherCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
