Home Account Information Date: MM slash DD slash YYYY Prepared By:*Alonso, FrancescaBalco, CraigCarrizo, LissethDugan, LeeAnnGraham II, MarkHill, CaitlinHilliard, SherrinKontodiakos, MichaelLamb, KaylaLamb, ShelbyLevi, DouglasLuciano, CarmenMella, TonyPirko, PhyllisWeaver, AlexWeaver, CassidiWheeler, TomYoung, 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 Contact Phone Email Text Select One: HO-3: Home Owners Policy HO-6: Condo Owners Policy DP-3: Dwelling Fire/Renters Occupation: Date of Birth: MM slash DD slash YYYY Physical Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different than primary): Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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: Primary Secondary Seasonal Any Rental? Vacant Will There be Any Renovations? Yes No What Months will the property go unoccupied? (only answer if not primary residence)** If home over 25 yrs, recommend 4 point or roof cert Yes No ***Do You have wind mit inspect Yes No *Year built Sq feet heated Construction type: Block Frame # of stories If 2+ stories verify 2nd story Block Frame Current Carrier (if applicable) New closing? / Renewal date? New closing Renewal date Date of Closing 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 Name Realtor PhoneRealtor Email Mortgage Broker Name Mortgage Broker PhoneMortgage Broker Email Current Premium $ Have you been non renewed for property insurance in last 5 years? Yes No # of Bedrooms and Bathrooms Roof covering type Year Replaced Any portion of roof flat? Yes No Is flat portion over living area? Yes No Please list the age of the following:HVACElectricalPanel BrandPlumbing/Water HeaterPurchase Price/Date? Current limits? Any claims in last 5 years for ANY property Yes No If Yes, details, dates, amount, type:Is there a pool? Yes No If yes, screened enclosure or fence surrounding pool?NeitherScreened EnclosureFenceFireplace? Yes No Garage (attached or detached)None123Any Porches/Decks/Patio/Lanai? Sq Ft: Is there a Diving Board, Slide or Trampoline? Any ANIMALS on property? Yes No If Yes, type:Monitored Fire/Burglar Alarm: Yes No Flood Zone Yes No REC. PRP*Has any named Insured had any voluntary or involuntary repossession, foreclosure, bankruptcy, felony, or DUI during the past (5) five years? Yes No *Does Client want a Jewelry or personal Articles Proposal? Yes No Do 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.PhoneThis field is for validation purposes and should be left unchanged.
