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10620 Griffin Rd #201, Cooper City, FL 33328
(954) 436-5630
customerservice@deweyinsurance.com
Why Us?
Leave A Review
Refer Friends & Family
Testimonials
About Us
Insurance Products
Auto Insurance
Homeowners Insurance
Boat Insurance
ATV & Powersports
Condo Insurance
Flood Insurance
Motorcycle Insurance
Renters Insurance
Specialty Dwelling Insurance
Umbrella Insurance
Contact
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Avatar Application Information
Avatar Application Information
Name(s) of all owners:
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Phone number
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Can we text you at this phone number?
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Yes
No
EMAIL ADDRESSES FOR ALL SIGNERS: (The application must be signed by all applicants. We will send the forms to you to sign electronically. If you do not want to sign electronically please note how you would like the application sent to you.)
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Property address:
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Mailing address if different than property address:
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Prior address for the last 3 years:
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Date(s) of birth for all applicants:
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Occupation(s) for all applicants:
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List all mortgages on the property with the name, address, loan number and phone number of each company:
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Does the mortgage company escrow (pay for the insurance)?
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Yes
No
No Mortgage
Number of residents of the house:
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List all household residents with their relationship to applicant(s):
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Do you have any losses that occured in last 5 years? If yes, give date of loss, description, amount paid, is the claim still open? and have all repairs been made?
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Do you have wood burning stove at home?
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Yes
No
Does the applicant have at least 1 year of current homeowner insurance, unless a first time home buyer?
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Yes
No
Is the residence premises vacant or UNoccupied?
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Yes
No
Will the residence premises be occupied by the applicant and/or co-applicant?
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Yes
No
Will the residence premises be the applicant and/or co-applicant's Primary residence?
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Yes
No
Will the residence premises be the applicant and/or co-applicant's Secondary residence?
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Yes
No
Will the residence premises be the applicant and/or co-applicant's Seasonal residence?
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Yes
No
How many families will occupy the residence premises?
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Will the residence premises have continuous UNoccupancy of 3 or more consecutive months, or a total UNoccupancy of six or more months during any 1 year period?
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Yes
No
Will more than two boarders reside at the residence premises? If yes, how many?
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Has the roof been completely replaced since the dwelling was initially constructed? If yes, what year?
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Number of losses other than lightning, tornado, hail, or hurricane, whether or not paid by insurance during the last 3 years at this, or any other location?
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Does anyone at the residence premises smoke tobacco products?
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Yes
No
Has either the applicant or co-applicant, if applicable, attained the age of 60 years or is at least 55 and retired?
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Yes
No
Will the applicant make the residence premises available for inspection?
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Yes
No
Is the residence premises in a state of disrepair, reflect lack of maintenance, have existing damage with no definitive intent to repair, or located in an area that is being condemned?
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Yes
No
Has the applicant or co-applicant ever been cancelled or non-renewed for material misrepresentation or insurance fraud or convicted of arson?
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Yes
No
Has the applicant or co-applicant ever brought, made or filed a liability claim against any person or entity? If yes, please explain:
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Has the applicant or co-applicant (at this or any other location or insured property) had 2 or more losses, excluding weather related, or any non-weather loss in excess of $10,000, or any fire or liability claims in the last 3 years, whether or not reported to insurance?
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Yes
No
Is there a buried oil tank?
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Yes
No
Is there a skateboard or bicycle ramp on the property?
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Yes
No
Is there a swimming pool or hot tub on the property? If yes, Is the swimming pool completely and permanently secured with a self-latching gate or pool cage? Is there a pool slide and/or diving board on the property?
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Does any applicant own or keep any all terrain vehicle(s) (ATV)?
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Yes
No
For the following questions: Does the applicant, co-applicant or any person who resides at the residence premises own any of the following animals, or are any of the following animals kept on the property?
Any of the following dogs (pure- or mixed-breed): akita, american pit bull terrier, american staffordshire terrier, catahoula leopard, chow, doberman-pincher, german shepherd, husky, malamute, presa canario, pit bull, rottweiler, staffordshire bull terrier, or wolf?
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Yes
No
More than 3 livestock, farm or saddle animals?
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Yes
No
Any animal that has bitten, attacked or caused injury to any person or animal, or property damage?
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Yes
No
Any exotic animals or reptiles?
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Yes
No
Is the dwelling's roof covered with rolled tar paper, tin, or untreated wood or is more than 10% of the roof over a living area flat?
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Yes
No
Does the dwelling have a properly functioning and professionally installed heat source that is thermostatically controlled?
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Yes
No
Is the dwelling in the course of construction or under renovation?
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Yes
No
Is the dwelling homemade or rebuilt, or has it been extensively remodeled?
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Yes
No
Is the dwelling a modular home?
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Yes
No
Is the dwelling classified as a mobile or manufactured home, prefabricated or kit home, or log home?
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Yes
No
Was the dwelling constructed by any unconventional design or for other than habitational purposes?
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Yes
No
Are there any structures on the property constructed partially or entirely over water?
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Yes
No
Is the residence premises isolated and/or not visible from a paved road or neighboring residence?
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Yes
No
Is the residence premises accessible year round to fire fighting equipment?
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Yes
No
Is the residence premises located on more than ten (10) acres?
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Yes
No
Is the residence premises located on a farm, ranch, orchard or grove, or where farming or ranching operations take place?
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Yes
No
Is the residence premises owned by a corporation, LLC, partnership, estate, trust, or association?
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Yes
No
Is the residence premises a fraternity, sorority or rooming house, or any other similar arrangement?
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Yes
No
Is there any business or commercial exposure on the property that would not be eligible for coverage under the permitted incidental occupancy endorsement?
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Yes
No
Is there, or has there ever been, any sinkhole activity on the property the applicant is aware of or has the applicant ever filed a sinkhole claim on the property?
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Yes
No
Is the residence premises on a landfill previously used for refuse?
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Yes
No
Are there 3 or more mortgages?
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Yes
No
Is there a licensed / registered daycare on the property? If yes, is there a liability policy in force?
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Does the residence premises use a portable space heater or open flame as the primary source of heat, have any "knob & tube" wiring in use, have a potentially hazardous electrical condition, aluminum branch wiring, or electrical service less than 100 amps?
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Yes
No
Is there any polybutylene plumbing?
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Yes
No
What is the age of the water heater?
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Does the dwelling utilize EIFS (exterior insulation finish system) construction techniques?
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Yes
No
Any other residence owned, occupied, or rented by the applicant or co-applicant? If yes, give details:
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Does the applicant or co-applicant own a golf cart that is kept on the property? If yes, how many?
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Does the applicant have any other insurance with this company? If yes, list additional policy number(s):
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Is the residence premises currently insured? if yes, give name of company and expiration date of policy:
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Is the residence premises for sale?
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Yes
Yes, I am buying the house as a new purchase
No
Is the residence premises over 30 years of age and less than 100 years of age?
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Yes
No
Does the house have existing damage?
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No
Yes
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