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First Name*
Phone number*
Date of birth*
Occupation*
Property Address (Address, City, State, ZIP)*
Mailing Address (Address, City, State, ZIP)*
If there's a mortgage please include: Name, Address and Loan #*
Requested Policy Effective Date*
Will there be an additional insured? If so, what is their name (person or company)
Within the last 5 years, has the application experienced:*
Is there insurance in place include Carrier name and Expiration date
Date you purchased the property*
Use of home*
If rental, how many weeks out of 52 is it rented?
Have you ever been declined for insurance?*
Do you want to add additional coverage?*
Is the home a mobile home?*
Does the home have knob and tube wiring?*
Is the home on more than 200 acres?*
Does the home have Polybutylene Plumbing?*
Is the primary heat source a portable space heater?*
Has the client had 4 or more claims in the past 3 years?*
Will there be any construction/renovations (Builder’s Risk) during this policy?
Any claims open with un-repaired damage?*
Policy form?*
Choose what coverage limits you would like for Dwelling*
Choose what coverage limits you would like for Contents*
Choose what coverage limits you would like for Loss of Use*
Choose what coverage limits you would like for Separate Structure *
Medical*
Liability coverage requested*
Distance to Fire Station (miles)
Age of Home or full remodel?*
Home Construction?*
Exotic home Construction explanation
Interior sprinkler*
Foundation*
Alarm*
Roof*
Please explain
Wiring*
Plumbing*
Other plumbing explanation
Roof condition*
Years since roof replaced/repaired*
Type of building*
Heating*
Number of families in the home*
Number of living at the location*
When was the home originally built*
Square footage*
Day care at the home?*
If yes, how many children
Any lakes ponds on the property?*
Is there a wood stove on the premises?*
Is the dwelling on a National Historic Register?*
Are there animals on the premises?*
Any residence employees? (Housekeeper, butler, caretaker, nannie, etc.)
Are there animals on the premises?*
Do you want dog liability?*
Is there a swimming pool?*
Is it fenced? (pool)
Any business operating from the home (home based)?*
Any claims in the past 3 years? If yes, I need the below for each claim*
Date of occurrence
Clause of loss
Amount paid out
What preventive measures have been taken to prevent future loss for same type of claim
Is the claim open?
Any additional information you would like to add?
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