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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
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Federated National Application Info
Federated National Application Information
Name of all owners:
*
Phone number:
*
Do we have permission to text you at that phone number?
*
Yes
No
Email address(es) for all applicants:
*
Property address:
*
Applicant's mailing address:
*
Occupation for all owners:
*
Employer's name for all owners:
*
Years employed w/ current employer:
*
Years employed in this occupation:
*
Marital status:
*
Date of birth for all owners:
*
What is the age of the roof?
*
Who occupies the house?
*
Owner occupied
Owner occupied, secondary residence
Owner occupieid, seasonal residence
Tenant occupied
Vacant
Does the home have any active polybutelene plumbing?
*
No
Yes
Does applicant(s) or tenant(s) have any animals or pets? (If yes, please list the type, breed and if there is any attack history)
*
Have you had any claims on this or any other property in the last 3 years? If yes, please give date(s) of loss, type of damage (theft, water etc) amount paid, if damage is repaired and if claim is closed:
*
Is there a swimming pool on the property? 2) If yes, is it screened? fenced? 3) Is there a diving board or pool slide?
*
Any prior sinkhole claims filed for this location?
*
Yes
No
Any farming or other business conducted on the premises (including day/child care?
*
Yes
No
Any existing or unrepaired damage to the insured location?
*
Yes
No
Any uncorrected fire, building code violations or existing or unrepaired damage?
*
Yes
No
During the last 25 years has any applicant been convicted of arson?
*
Yes
No
Is there a skateboard/bike ramp or any other unusual liability exposure on the premises?
*
Yes
No
Is there a trampoline on the premises?
*
Yes
No
Purchase date:
*
Purchase price:
*
Any hazards including flooding, brush fire, forest fire, landslide etc?
*
Yes
No
Any residence employees (employees that work and live in your home)?
*
Yes
No
Is the property currently for sale?
*
Yes
No
Yes, but I'm purchasing/new purchase
Any other residence owned, occupied or rented? If yes, give details:
*
Any foreclosures, bankruptcy or repossessions in the past five years?
*
Yes
No
Does the applicant own any recreational vehicles?
*
Yes
No
Is the property within 300 feet or a commerical or non-residential property?
*
Yes
No
Was the structure originally built for other than a private residence or converted?
*
Yes
No
Is there a lead paint hazard?
*
No
Yes
Is there a fuel/oil tank on premises?
*
Yes
No
Have any applicants had any coverrage declined, canceled or non-renewed in the last three years?
*
Yes
No
Is the building undergoing renovation or reconstruction? If yes, give details:
*
If the building is under construction, is the applicant the general contractor?
*
Yes
No
Property is not under construction
Is the electrical on circuit breakers?
*
Yes
No
Mortgage company name, address and loan number:
*
Does your mortgage escrow (pay for insurance)?
*
Yes
No
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Claims
Payments
