Home Account Information Date: Date Format: MM slash DD slash YYYY Prepared By:*Alonso, FrancescaBalco, CraigBass, SandyD’Hondt, MichaelDugan, LeeAnnGonzalez, BentleyHale, AllanHilliard, SherrinKennedy, BrewaLamb, KaylaLevi, DouglasLuciano, CarmenMella, TonyNazario, JimmyPirko, PhyllisRhoads, DanSalvator, MatthewSaroukos, AnthonyShepard, NikkiShinard, CleoWilliams-Lewis, NicoleWoods, DarrylYoung, AmyHow did you hear about us?Who can we thank for referring you to our office?Name:Email Address:* Phone Number Cell:Preferred Method of ContactPhoneEmailTextSelect One:HO-3: Home Owners PolicyHO-6: Condo Owners PolicyDP-3: Dwelling Fire/RentersOccupation:Date of Birth: Date Format: MM slash DD slash YYYY Physical Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different than primary): Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Wouldn’t it feel good to know you are getting the proper insurance protection & the best possible price?Other than price what is most important to you?Use of Property:PrimarySecondarySeasonalAny Rental?VacantWill There be Any Renovations?YesNoWhat Months will the property go unoccupied? (only answer if not primary residence)** If home over 25 yrs, recommend 4 point or roof certYesNo***Do You have wind mit inspectYesNo*Year builtSq feet heatedConstruction type:BlockFrame# of storiesIf 2+ stories verify 2nd storyBlockFrameCurrent Carrier (if applicable)New closing? / Renewal date?New closingRenewal date Date of Closing Date Format: MM slash DD slash YYYY In order to better serve our clients, we gather the realtor and mortgage contact information to help make your life easier to coordinate with all parties involved for your closing, so please provide:Realtor NameRealtor PhoneRealtor Email Mortgage Broker NameMortgage Broker PhoneMortgage Broker Email Current Premium $Have you been non renewed for property insurance in last 5 years?YesNo# of Bedrooms and BathroomsRoof covering typeYear ReplacedAny portion of roof flat?YesNoIs flat portion over living area?YesNoPlease list the age of the following:HVACElectricalPanel BrandPlumbing/Water HeaterPurchase Price/Date?Current limits?Any claims in last 5 years for ANY propertyYesNoIf Yes, details, dates, amount, type:Is there a pool?YesNoIf yes, screened enclosure or fence surrounding pool?NeitherScreened EnclosureFenceFireplace?YesNoGarage (attached or detached)None123Any Porches/Decks/Patio/Lanai? Sq Ft:Is there a Diving Board, Slide or Trampoline?Any ANIMALS on property?YesNoIf Yes, type:Monitored Fire/Burglar Alarm:YesNoFlood ZoneYesNoREC. PRP*Has any named Insured had any voluntary or involuntary repossession, foreclosure, bankruptcy, felony, or DUI during the past (5) five years?YesNo*Does Client want a Jewelry or personal Articles Proposal?YesNoDo you currently own any recreational vehicles? (Boats, ATVS, RVs, Motorcycles) If so, please list each: Press the "+" button to list another vehicle.Notes:We want to let you know how we get paid. We get paid two ways; one is a commission that comes from the company directly, not from your pocket, and the other is by referrals from our clients. So if we do a good job for you, we hope that you would consider to refer us to your friends, family & co-workers.NameThis field is for validation purposes and should be left unchanged.
