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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
Start Your Quotes
Start Your Quotes
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Bass Application Information
Bass Application Information
Name(s) of all owners:
*
Mailing address:
*
Property address:
*
Phone number
*
Do we have permission to text you at this phone number?
*
Yes
No
Date(s) of birth for all owners:
*
EMAIL ADDRESS(ES) 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.)
*
Are there any plumbing or roof leaks?
*
No
Yes
Is the insured currently or have in the past been in a high profile profession?
*
No
Yes
Has Any Coverage Been Declined, Cancelled or Non-Renewed During the Last Three (3) Years?
*
No
Yes
Has Applicant Had a Foreclosure, Repossession or Bankruptcy During the Past Five Years?
*
No
Yes
Has Applicant Had a Judgement or Lien During the Past Five (5) Years:?
*
No
Yes
During the Last Five (5) Years [Ten (10) Years in Rhode Island], Has Applicant Been Indicted For or Convicted of Any Degree of the Crime of Fraud, Bribery, Arson or Any Other Arson-Related Crime in Connection With This or Any Other Property?
*
No
Yes
Any Uncorrected Fire or Building Code Violations?
*
Yes
No
Does the building contain: Active knob & tube wiring, Active aluminum wiring, Galvanized plumbing or fuses boxes?
*
Yes
No
Does the building have circuit breakers?
*
Yes
No
Has the property been updated or fully renovated?
*
Yes
No
Any prior losses? (if yes, please give the dates, type of loss, amount paid, if the claim is closed and if the damage is repaired)
*
Any dogs or exotic pets on premises: (if yes, give type of pet including breed if it is a dog and if there is an attack history)
*
Any Flooding, Brush, Forest Fire Hazard, Landslide ETC?
*
No
Yes
Is Property Within 300 Feet of a Commercial Property?
*
No
Yes
Was the Structure Originally Built for Other Than a Private Residence and Then Converted?
*
No
Yes
Any Lead Paint Hazard?
*
No
Yes
Is There a Manager on the Premises?
*
No
Yes
Manager's name and phone # if manager is on premises:
*
Is There a Security Attendant?
*
No
Yes
Is the Building Entrance Locked?
*
No
Yes
Please provide the year the ROOF has been updated:
*
Please provide the year the WIRING has been updated:
*
Please provide the year the PLUMBING has been updated:
*
Please provide the year the HEATING has been updated:
*
Is there a swimming pool? If yes, is it completely fenced? Is there a diving board or pool slide?
*
Does Property Have Fire Extinguishers?
*
Yes
No
Does the building contain the following: Active knob & tube wiring, Active aluminum wiring, Galvanized plumbing and/or Fuses boxes? (List all that are present)
*
Does the building have Circuit Breakers?
*
No
Yes
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