|
|
Applicant Information
|
|
|
|
Effective Date
|
|
|
|
Email Address
|
|
|
|
|
|
First Name
|
|
|
|
Last Name
|
|
|
|
|
|
Marital Status
|
|
|
|
Phone Number
|
|
|
|
|
|
|
|
|
|
Mailing Address
|
|
|
|
City
|
|
|
|
|
|
State
|
|
|
|
Zip Code
|
|
|
|
|
|
Property Information
|
|
|
|
Physical Address
|
|
|
|
City
|
|
|
|
|
|
State
|
|
|
|
Zip Code
|
|
|
|
|
|
Year Built
|
|
|
|
|
|
Coverages
|
|
|
|
Coverage A (Dwelling)
|
|
|
|
|
|
|
|
Coverage B (Other Structures)
|
|
|
|
|
|
|
|
Coverage C ( Personal Property)
|
|
|
|
|
|
|
|
Coverage D (Loss Of Use)
|
|
|
|
|
|
|
|
Coverage E (Personal Liability)
|
|
|
|
|
|
|
|
Coverage F (Medical Payments)
|
|
|
|
|
|
|
|
Deductible (All claims except hurricanes)
|
|
|
|
|
|
|
|
Hurricane Deductible
|
|
|
|
|
|
|
|
Dwelling Information
|
|
|
|
Construction Type
|
|
|
|
|
|
|
|
Property Type
|
|
|
|
|
|
|
|
Heated Area (Square Footage)
|
|
|
|
|
|
|
|
Number of Stories
|
|
|
|
|
|
|
|
Dwelling Use
|
|
|
|
|
|
|
|
Primary Heat Source
|
|
|
|
|
|
|
|
Was Your Primary Heat Source Professionally Installed?
|
|
|
|
|
|
|
|
Do you have a central Burglar Alarm?
|
|
|
|
|
|
|
|
Do you have a central Fire Alarm? (not smoke detector)
|
|
|
|
|
|
|
|
Does your home have Open or Closed Foundation
|
|
|
|
|
|
|
|
Purchase Information
|
|
|
|
Is this a new Purchase or Lease?
|
|
|
|
|
|
|
|
Have you had continuous Homeowner insurance for at least 1 year with no lapse in coverage?
|
|
|
|
|
|
|
|
Prior Homeowner Insurance Carrier
|
|
|
|
|
|
|
|
Expiration date of current policy
|
|
|
|
|
|
|
|
Update Information
|
|
|
|
Electrical Updates Last Done
|
|
|
|
|
|
|
|
Plumbing Updates Last Done
|
|
|
|
|
|
|
|
Roofing Updates Last Done
|
|
|
|
|
|
|
|
Heating Updates Last Done
|
|
|
|
|
|
|
|
Other Information
|
|
|
|
Distance to Fire hydrant
|
|
|
|
|
|
|
|
Distance to closest Fire Station
|
|
|
|
|
|
|
|
Floor Unit Located On
|
|
|
|
|
|
|
|
Please list below if you need any items scheduled & the amount (Jewelry, Furs, Guns, Golf Carts, Coin
Collection, Fine Arts, Golf Equipment, Non-Professional Cameras & Equipment, Non-Professional Musical
Instruments, Silverware, Stamp Collections
|
|
|
|
|
|
|
|
|
|
|
