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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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Edison Insurance Application Information
Edison Insurance Application Information
Name (all owners):
*
Property Address
*
Email address
*
Mailing address
*
Phone number(s)
*
Do we have permission to text you at that phone number?
*
Yes
No
Date(s) of birth for all owners
*
Occupation(s) for all owners
*
Relationship of applicants (example: married, mother and son, etc)
*
Do we have your permission to run credit/loss history reports?
*
Yes
No
Prior address for the last 3 years
*
Number of amps for electrical system
*
Plumbing type (copper, PEX, PVC, full or partial galvanized, full or partial polybutelene etc)
*
In addition to the First Named Insured and Co-Applicant (if applicable), do other individuals occupy the dwelling? If yes, please provide names, dates of birth and relationship to insured:
*
At the time of purchase and/or building this home, were there any disclosures on the residence and/or property to be insured concerning sinkhole activity and/or cracking, movement, raveling, listing, leaning or buckling of a foundation, floor or wall?
*
Yes
No
Does the residence and/or property to be insured under this policy have any known or suspected sinkhole or sinkhole activity, or has it experienced any cracking, movement, raveling, listing, leaning or buckling of a foundation, floor or wall, whether repaired or not?
*
Yes
No
Has the applicant(s) ever requested a sinkhole investigation, ground study, and/or sinkhole inspection for any reason other than an inspection to request sinkhole insurance coverage for the house and/or property to be insured?
*
Yes
No
Has the applicant(s) and/or additional insureds ever submitted a claim for sinkhole damage/loss on the residence and/or property to be insured?
*
Yes
No
Has the applicant(s) ever been convicted of a felony or insurance fraud?
*
Yes
No
Will the applicant(s) be living at and occupying the home within 30 days of the effective date of the application?
*
Yes
No
Are the applicant(s) and all additional insureds, if applicable, listed on the deed?
*
Yes
No
Is there any existing damage on the home, or is the home under construction, renovation, or repairs?
*
Yes
No
Is there a child or adult daycare, assisted living care or any rehabilitation activities on the property?
*
Yes
No
Is any business conducted on the property?
*
Yes
No
Do any of the following exist on the property: Trampoline, Skateboard Ramp, Empty Swimming Pool, Bicycle Ramp, Diving Board?
*
Yes
No
Do you have any pets? If yes, list the type, breed and whether the pet has ever attacked anyone:
*
Does the property have a pool? If yes, is the pool fenced or screened?
*
Any 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? If yes, list the date of loss, type of loss, amount paid and whether the damage is repaired:
*
Mortgage company name, phone number and loan number:
*
Does your mortgage company escrow?
*
Yes
No
Purchase date
*
Purchase price
*
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Email
Claims
Payments
