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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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Citizens Clearinghouse Application
Citizens Clearinghouse Application Information
Name(s) of all owners
*
Date(s) of birth for all owners
*
Email address for all owners:
*
Occupation(s) for all owners:
*
Relationship of all owners:
*
Phone number:
*
Do we have permission to text you at this phone number?
*
Yes
No
Property address:
*
Is the property address different than your mailing address?
*
No
Yes
If yes, list the mailing address:
*
Credit report consent: IF YES: I consent to the obtaining or preparation of a credit report by a requesting Participating Insurer and my agent of record. I understand that these reports must be handled in the strictest confidence. Information as to the nature and scope of these reports will be provided to me upon request. A list of Participating Insurers can be found by requesting from Dewey Insurance Agency: IF NO, I do not consent to the obtaining or preparation of a credit report. I understand that declining to consent to a Participating Insurer obtaining a credit report may result in fewer quotes being made by Participating Insurers through the Clearinghouse:
*
Yes
No
Has the application had insurance on this property? (If yes, please provide name of company, expiration date and policy number)
*
Dwelling Occupancy? (Primary, Secondary, Seasonal, Unoccupied, or Vacant):
*
Date Purchased or leased:
*
Purchase price:
*
Is the home under construction or renovation?
*
No
Yes
Exterior Walls Construction? (Stucco, Siding, Wood shakes, etc.):
*
Is the dwelling built on a continuous masonry foundation?
*
No
Yes
Roof Condition:
*
Excellent
Good
Fair
Poor
Does the dwelling have a covered porch?
*
No
Yes
Is the property located within 1500 feet of salt water?
*
No
Yes
Is any part of the structure exposed to open seawater greater than ¼ mile in width?
*
No
Yes
Is the dwelling located within 300 feet of a commercial structure?
*
No
Yes
Is the property situated on more than 5 acres?
*
No
Yes
Is the dwelling currently for sale?
*
No
Yes
Yes, but it is a new purchase for me
Is the home located inside city limits?
*
No
Yes
How far away is your home from a fire hydrant? (feet):
*
How far away is your home from a fire station? (miles):
*
Is the property readily accessible year round to the fire department and its equipment?
*
No
Yes
How many units or apartments?
*
Number of units in firewall?
*
Do you have any of the following protective devised in your home? (please note all that apply) smoke detector, fire extinguisher, fire detection, burglar alarm, dead bolt locks, indoor sprinkler system:
*
Number of families:
*
Primary Heat Source: (central, wall units etc)
*
Indicate Heating type (Electric, Gas, Oil, Etc.):
*
Is the heating device portable?
*
No
Yes
Is there any heating device with an open flame?
*
No
Yes
Has the Heating system been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:
*
Has the Plumbing been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:
*
What type of plumbing does the house have? (PVC, Copper, Polybutelene, galvanized etc, please note all types that are present in the house)
*
Has the roof been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:
*
Has the electrical wiring been renovated or replaced? IF YES, indicate the year updated and whether it was a partial or complete update:
*
What type of electrical system:
Circuit breakers
Fuses
Is the name brand of your electrical box any of the following: Federal Pacific, Challenger, Stab-Lok, Zinsco, Zinsco-Sylvania, GTE Sylvania or Kearney?
*
Indicate all that apply to the electrical system: knob & tube wiring, service less than 100 amps, aluminum branch wiring, cloth wiring:
*
Are all updates or renovations done by a Licensed Contractor?
*
No
Yes
Is there a swimming pool on the premises? If yes is it fenced or screened? Is there a diving board or pool slide?
*
Are any of the following located on the premises: Trampoline, Skateboard or Bicycle Ramp, Treehouse, Outdoor appliance, Inoperable motor vehicle(s) not secured in a garage or a structure, Vicious or exotic animals, animals with a history or biting, Horses or livestock for business, other unusual or dangerous conditions?
*
Is there a business on the premises? (including religious services and day care):
*
No
Yes
Have you made any claims on this, or any other property you own in the past 5 years? (If yes list type, amount paid and date of loss)
*
Are there any dogs on the property? If yes, advise of the breed(s):
*
Is the dwelling or any structure on the premises newly constructed, or rebuilt, repaired, restored, or remodeled to increase the total square footage of finished area by more than 25%, pursuant to a permit applied for after July 1, 2015?
*
No
Yes
Mortgage company name, address, loan number and phone number:
*
Does your mortgage company escrow?
*
No
Yes
How many months of the year is the dwelling unoccupied consecutively?
*
Is the property rented on a weekly or short term basis?
*
No
Yes
Do you live in a limited access/ gated community?
*
No
Yes
Do any of the residents smoke?
*
No
Yes
Is your home visible to neighbors?
*
No
Yes
Is there manned security on premises?
*
No
Yes
Are there any residence employees?
*
No
Yes
Do you own any recreational vehicles? (golf carts, ATV, etc)
*
Was dwelling originally built for purposes other than a residence and later converted for residential use?
*
No
Yes
Is risk constructed in whole or in part with EIFS (Enhanced Insulation and Finishing System)?
*
No
Yes
Is the dwelling currently for sale?
*
No
Yes
Yes, but this is a new purchase for me
Are there any uncorrected fires or building code violations?
*
No
Yes
Does the number of Roof overlays exceed 1?
*
No
Yes
Is the roof damaged or does the roof have visible signs of leaks?
*
No
Yes
Does any person who will be insured under the policy have knowledge that repairs have been made to the dwelling and/or property relating to sinkhole activity?
*
No
Yes
Does the dwelling or screen enclosure have any existing damage? (Including but not limited to cracking, settlement or sinkhole damage)
*
No
Yes
Has the applicant ever requested a sinkhole investigation or submitted a claim for sinkhole loss?
*
No
Yes
Are you or any person who will be an insured under this policy aware of any loss assessment or special assessment on the “residence premises” in the past 5 years?
*
No
Yes
Is there any sinkhole damage without proper remediation action taken to stabilize the home?
*
No
Yes
Do you have any knowledge of any prior repairs made to structures on premises for cracking damage?
*
No
Yes
Has any named insured had a foreclosure, repossession or bankruptcy during the past 5 years?
*
No
Yes
Is the risk a foreclosed property?
*
No
Yes
Has applicant(s) ever been convicted of a felony?
*
No
Yes
During the last 15 years has any applicant been convicted of insurance fraud?
*
No
Yes
During the last 25 years has any applicant been convicted of any degrees of a crime of arson?
*
No
Yes
Has the insured ever been cancelled, non-renewed or declined for insurance coverage? (Other than non-payment)
*
No
Yes
Has applicant(s) ever been involved in a first party lawsuit against an auto of homeowners insurance company?
*
No
Yes
Are there any assisted living activities or any other form of in-home care on the premises?
*
No
Yes
Do you have any open claims?
*
No
Yes
Is the dwelling subject to brush or forest fires?
*
No
Yes
Is there an underground fuel tank on the premises?
*
No
Yes
Is structure constructed partially or entirely over water?
No
Yes
Are there any porches or decks more than 2ft off the ground or that have more than 3 steps without handrails or guardrails?
*
No
Yes
Are all spas/hot tubs covered and locked?
*
No
Yes
N/A - no spas or hot tubs
Indicate the number of dogs on premises:
*
Has any applicant been canceled for material misrepresentation on an application for insurance or on a claim in the past 7 years?
*
No
Yes
Is the dwelling used as a fraternity or sorority house or any similar housing arrangement?
*
No
Yes
Does the dwelling show signs of settlement or cracking of the walls, floor or foundations?
*
No
Yes
Are there any signs of sinkhole activity on the property such as shifting, or bulging of a foundation, wall or roof?
*
No
Yes
Does any person who will be an insured under this policy have knowledge of any sinkhole investigation, ground study, structural evaluation, and/or sinkhole inspection performed due to a sinkhole claim or for any reason other than an inspection to request sinkhole insurance for the property?
*
No
Yes
Does any person who will be an insured under this policy have knowledge that repairs have been made to the dwelling and/or property relating to sinkhole activity?
*
No
Yes
Does the dwelling have any existing damage?
*
No
Yes
Is the property in a state of disrepair?
*
No
Yes
Is the dwelling, or other structure homemade, rebuilt or constructed with extensive remodeling on a "do-it-yourself" basis?
*
No
Yes
Was the dwelling orignally built for purposes other than a residence and later converted for residential use?
*
No
Yes
Is the property located on a landfill previously used for refuse?
*
No
Yes
Is the dwelling rented for periods of 30 days or less?
*
No
Yes
Not rented ever
Is the dwelling advertised or held out for rental to guests for short term rental periods?
*
No
Yes
Not rented ever
Was the dwelling ever moved from its original foundation?
*
No
Yes
Is home currently condemned?
*
No
Yes
Is the dwelling vacant or unoccupied (new purchases or buildings nearing completion are considered vacant if they are not occupied within 30 days of the requested effective date)?
*
No
Yes
Does the property have any polybutylene piping?
*
No
Yes
Does dwelling have a flat roof (pitch less than 1 ft per 12 ft)?
*
No
Yes
Does dwelling have utility service?
*
No
Yes
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