Homeowners Intake Form

New or Existing Customer *

New Customer
Existing Customer

Name *

First

Last

Phone *

Email *

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your property address different from your mailing address? *

Yes
No

Property Address *

Address Line 1

Address Line 2

City

State

Zip Code

Have you lived at your current address for less than 3 years? *

Yes
No

Please Provide Your Prior Address *

Address Line 1

Address Line 2

City

State

Zip Code

Paperless Discount? *

Yes
No

Prior Loss within 5 Years? *

Yes
No

Please Explain *

Do we have your permission to access claims history, run motor vehicle and insurance reports? *

Yes
No

If no, we cannot quote the insurance.

Quote Effective Date *

Property Type *

Homeowners
Renters
Rental Property

Type of Dwelling *

Mortgagee? *

Yes
No

Is premium Escrowed? *

Purchase Date *

(MM/YY)

Amount purchased *

Year Built *

Square footage *

Number of stories *

Occupancy *

Tenant
Vacant

Type of Rental *

Short Term
Long Term

Monthly Rental Income? *

Household Members

Name *

Relationship *

Sex *

Male
Female

Marital Status *

Single
Married

DOB *

MM/DD/YYYY

Occupation *

Education Level *

More household members? *

Yes
No

Household Members

Current Carrier (Type N/A if none) *

Effective Date *

Expiration date *

Premium

Number of years covered *

Have you been canceled or non-renewed in the last 3 years? *

Yes
No

Please explain *

Dwelling Coverage A ( Input 0 for New Purchase) *

Personal Property Coverage C

Liability *

Medical Payment *

Deductible *

Wind/Hail Deductible

Sewer/Drain Back-Up *

Equipment Breakdown *

$50k
$100k

Service Line *

$5k
$10k
$20k

Identity Theft? *

Yes
No

Earthquake? *

Yes
No

Flood? *

Yes
No

Please Explain *

Scheduled Items? *

Yes
No

Type *

Approximate Value *

Roof Age *

Roof Material *

Please Specify *

Wiring Age *

Wiring Type *

Heating Age *

Heating Type *

Cooling Year *

Plumbing Year *

Foundation

What percentage of the property has this foundation type?

Must equal 100% (i.e., 50% slab, 50% basement

Foundation *

Percentage % *

Finished Basement *

Yes
No

Percent Finished

Type of Basement

Daylight
Walkout

Exterior Wall Material *

Garage *

Garage Type *

Number of Cars *

Dwelling Address 3

Carport *

Yes
No

Type of Carport

Number of Cars *

Detached Structures *

Yes
No

Type

Approximate Size

Approximate Value

Number of Full size Bathrooms *

Number of Three-quarter Bathrooms *

Number of Half Bathrooms *

Fireplace *

Yes
No

Type

Number of Fireplaces

Wood Burning Stove *

Yes
No

Hot Tub *

Yes
No

Does the hot tub have a cover? *

Yes
No

Pool *

Yes
No

Pool Type

Diving board *

Yes
No

Slide *

Yes
No

Fence *

Yes
No

Monitored Burglar Alarm *

Yes
No

Monitored Fire Alarm *

Yes
No

Dog *

Yes
No

Breed

Breed Type *

Bite History *

Yes
No

Trampoline *

Yes
No

Safety net *

Yes
No

Distance to fire department in miles *

Distance to fire hydrant in feet *

Home business *

Yes
No

Type Of Home Business *

Additional Comments?

Homeowners/Renters Intake Form

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

Household Members

What percentage of the property has this foundation type?

Breed