| New Purchase? |
Yes No |
| Closing Date? |
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| If no, what is your current insurance company and effective dates of policy? |
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| If no current coverage, Why? If policy has simply expired of lapsed, when/date? |
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| Applicant Name(s) (*) |
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| Email (*) |
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| Telephone Number (*) |
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| DOB |
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| Is the Applicant Single or Married? |
Single Married |
| Street Address |
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| City |
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| State |
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| Zipcode |
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| Is it a home, mobile home, townhouse, or condo? |
Home Mobile Home Townhouse |
| If yes to a Mobile Home, is it a single, double, or triple? |
Single Double Triple |
| If yes to a Townhouse, how many total units are attached? |
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| Number of Stories? |
1 2 3 4 5 |
| Exterior Construction (site built homes only) |
Frame Masonry Bricks Alumium Siding Vinyl Siding Hardeeboard Wood Asbestos Siding Other |
| Site built homes: foundation enclosed? |
Yes No (skirted with metal, vinyl, or lattice) |
| If yes, slab, bricks, or lattice? |
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| Mobile Homes: skirted/enclosed |
Skirted Enclosed |
| If yes, metal, vinyl, lattice, bricks? |
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| Year built or manufactured: |
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| Pool on Property? |
Yes No |
| If yes, is it fenced?? |
Yes No |
| If yes, is it screened? |
Yes No |
| Above ground or in ground? |
Above Ground In Ground |
| Diving Board? |
Yes No |
| Slide? |
Yes No |
| Fireplace? |
Yes No |
| Wood or Gas? |
Wood Gas |
| What is the age of the roof? (years) |
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| What is the shape of the roof? |
Gable Hip Flat Other |
| Roofing material? |
Metal Shingle Tile Other |
| Number of bedrooms? |
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| Number of bathrooms? |
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| Trampoline on Property? |
Yes No |
| Heated and cooled square footage of home? |
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| Garage or carport? |
Garage Carport |
| This property is/will be: |
Primary Owner Occupied Secondary Owner Occupied Long Term Tenant Occupied Short Term Tenant Occupied |
| If owner occupied, number of residents? |
1 2 3 4 5 6 7 8 9 10 |
| Are animals kept on the property? |
Yes No |
| If rental, are they allowed? |
Yes No |
| If yes please explain. Need to know type of animal and kind of breed? |
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| Is the property in a subdivision/park/neighborhood? NAME |
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| Amount of land property is located on? (if known) |
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| Is the property located within city limits? |
Yes No |
| Approximate distance to the nearest fire station? |
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| Are fire hydrants located near home or in neighborhood? |
Yes No |
| If home is a coastal property or out of our familiar area, how far is the home from coast/tidal waters, ocean? |
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| Amount of coverage required/requested? |
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| If new purchase, what is the purchase price? |
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| Is there a current or recent appraisal available? |
Yes No |
Does applicant have any history of:
Home insurance claims |
Yes No |
| Foreclosures? |
Yes No |
| Bankruptcies? |
Yes No |
| If yes, what year dissolved/discharged? |
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| Is there a monitored alarm system? |
Yes No |
| If yes, is it monitored for theft/burglary or fire? |
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