Prepared Insurance Application Information

Name(s) of all owners:*

Property address:*

Email address(es) for all signers:*

Phone number(s)*

Date(s) of birth:*

Marital status:*

Please provide us with a phone number so that we can call you to obtain social security numbers for all applicants:

Occupation(s):*

Total number of years employed in this occupation(s):*

Total number of years with current employer(s):*

Total number of years with previous employer(s):*

Current employer(s) name(s) and address(es):*

What is the age of the roof?*

Has the roof been patched?*

What is the age of the water heater?*

Is there a swimming pool?*

No
Yes

If you have a pool, how is the pool enclosed?*

The yard is completely fenced
The pool is completely enclosed in a screened patio
The pool is not enclosed
N/a - No pool

If you have a pool, does it have the following?*

Does NOT have a diving board and/or pool slide
Pool slide
Diving board
N/a - No pool

Does the house have a screened enclosure? If yes, what year was it built?*

Is Property Unoccupied for 3 Consecutive Months or More?*

No
Yes

Is the home's electrical system completely circuit breakers?*

No
Yes

Does the home's electrical system use fuses?*

No
Yes

Does the home's electrical system contain knob and tube or aluminum wiring?*

No
Yes

Number of electrical amps:*

Date A/C and heating system was last serviced:*

Are there any known plumbing leaks?*

No
Yes

Water heater location:*

Are smoke detectors located in close proximity to sleeping areas?*

No
Yes

Has the applicant had a foreclosure, repossession, short-sale, lien or bankruptcy during the last five years?*

No
Yes

During the last five years has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson, or any other arson related crime, theft or vandalism?*

No
Yes

Is the house currently for sale?*

No
Yes
Yes, it is a new purchase for me

Is home vacant?*

No
Yes

Will the home be occupied within 30 days of the effective date of the application?*

No
Yes
Yes, I am currently living there

Any other residences owned, occupied or rented? (If yes, please explain)*

Was the home in foreclosure or sold as a short sale and vacant at the time of purchase?*

No
Yes

Has there been a lapse in coverage of more than 30 days?*

No
Yes

Have you had any coverage declined, cancelled or non-renewed during the last 3 years?*

No
Yes

Is the building under construction or undergoing renovation or reconstruction? (If yes, please explain and give the estimated time of completion and the dollar value:*

If the building is under construction/renovation is the applicant a general contractor?*

No
Yes
N/a - Not under construction/renovation

Was the structure originally built for other than a private residence and then converted?*

No
Yes

is the property within 300 feet of a commercial or non-residential structure?*

No
Yes

Any farming or other business conducted on premises?*

No
Yes

Is property eligible for coverage under a commercial policy?*

No
Yes

Does the property have existing damage or evidence of disrepair/lack of maintenance?*

No
Yes

Any asbestos materials present in any part of your home (i.e. roofing, paint etc)?*

No
Yes

Does the property have prior sinkhole activity or is adjacent to a location with sinkhole activity?*

No
Yes

Any uncorrected fire code violations?*

No
Yes

Does dwelling have stairways with 3 or more steps or porches/decks over 2 feet off the ground without handrails?*

No
Yes

Are there any burglar or decorative bars on the windows?*

No
Yes

Is home located on dirt, unpaved or private access only road?*

No
Yes

If a fuel tank is on premises, has other insurance been obtained for the tank?*

No
Yes
N/a - No fuel tank on premises

Any lead paint hazard?*

No
Yes

Do any applicants or tenants have any animals or exotic pets/saddle animals? (If yes, please list the type, breed and whether the animal(s) have ever attacked anyone:)*

Do any applicants own any recreational vehicles (dune buggies, mini bikes, ATVs etc)? (If yes, list type and whether you have a separate policy for the vehicle:*

Is there a trampoline, skateboard ramp or bicycle ramp on the premises?*

No
Yes

Any full-time, residence employees?

No
Yes

Has any prospective insured ever been involved in a first party personal lines lawsuit against an auto or homeowners insurance company?*

No
Yes

Mortgage company name, phone number and loan number:*

Does your mortgage company escrow?*

No
Yes

Prior address(es) for the past three years:*

Any prior claims on this or any owned location? (If yes, list the type of claim(s), amount paid, date of claim(s) and if the damage is reparied)*

Purchase price:*

Purchase date:*