Step 1 of 6 16% Homeowners Intake FormCurrent Carrier Length of Time with CarrierLength of Time with Carrier - monthExpiration Date of policy MM slash DD slash YYYY Settlement Date (if new home purchase) MM slash DD slash YYYY Who lives in the House? Own Any of the following Watercraft Rental Properties Secondary Home Motorcycles/ATVs Payment MethodEscrowedInsured Full PayQuarterlyMonthlyEFTCCMailConstruction Style (Colonial, etc) Row/TownhouseCenterEndHome under Construction? Yes No Year BuiltSquare Footage (Excluding Finished Basement) Number of StoriesFoundationSlabBasementBasementCrawlspaceSump Pump? Yes No Battery Backup? Yes No Number of Claims in Last 5 Years 0 1 2 3 Loss # 1 Details Loss # 2 Details Pets at the Home? Yes No Dog Breed(s) Current CoveragesDwelling Personal PropertyLiability100K300K500K1MilMedicalDeductibleInteriorBedroomsBathrooms - FullBathrooms - HalfBathrooms - 3/4Bathroom GradeBuildersSemi-CustomCustomDesignerLuxuryKitchen(s) GradeBuildersSemi-CustomCustomDesignerLuxuryUntitledWall MaterialDrywall%Plaster%UntitledWall CoveringsPaint%Wallpaper%Paneling%UntitledFlooringHardwood%Carpet%Vinyl%Ceramic Tile%Last UpdatedHeatingElectricalPlumbingRoofUntitledHeating Type Electric Gas Propane Oil Central Air? Yes No ExteriorRoof Type Gable Flat Complex Vinyl Siding%Asphalt Shingles%Additional StructuresFireplace Gas Wood Gas Wood Wood Stove? Yes No Professionally Installed? Yes No Swimming Pool? Yes No Diving Board? Yes No Fence? Yes No Slide? Yes No Trampoline? Yes No EndorsementsIdentity Theft Yes No Home in an Association? Yes No Home in an Association? Yes No Sinkhole Coverage Yes No Ordinance or Law 25% 50% 75% Scheduled Personal PropertyJewelry Guns Coins Silver/Goldware Computers Cameras Golf Equipment Furs Fine Arts CreditsCentral Burglar Alarm Yes No Company Fire AlarmCentralLocalFire Extinguisher? Yes No Business registered to the home? Yes No Type of Business Doing AIRBnb at all? Yes No Any Household Employees? Yes No How far from Fire Department?mile(s)How far from Fire Hydrant?feetDo you have Personal Umbrella? Yes No Limitmillion Child # 1 NameDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver's License State Licensed Occupation Student Full Time Part Time B average or better? Yes No Attend School 100 Miles Away or more? Yes No Driver's Education - Behind Wheel and Classroom? Yes No Cell Phone NumberWork Phone NumberEmail address Child # 2 NameDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver's License State Licensed Occupation Student Full Time Part Time B average or better? Yes No Attend School 100 Miles Away or more? Yes No Driver's Education - Behind Wheel and Classroom? Yes No Cell Phone NumberWork Phone NumberEmail Address Umbrella / Excess Liability QuotingCurrent Carrier Date MM slash DD slash YYYY Length of Time with CarrierLength of Time with Carrier - monthsPayment MethodEscrowedInsured Full PayQuarterlyMonthly:EFTCCMailLimit of Coverage $ 1mil $ 2mil $ 3mil $ 4mil $ 5mil $ 10mil Other Swimming Pool on Premises? Yes No Fenced? Yes No Slide? Yes No Diving Board? Yes No Trampoline? Yes No Netted? Yes No Business in the Home Yes No Type of Business # of Cars Motorcycles? ATVs? Boats? Rental Properties? Secondary Homes? Fire Quoting - CondoCurrent Carrier Expiration Date of policyMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Length of Time with CarrierLength of Time with Carrier - monthsPayment MethodEscrowedInsured Full PayQuarterlyMonthlyEFTCCMailHome under Construction? Yes No Swimming Pool on Premises? Yes No Fenced? Yes No Trampoline? Yes No Netted? Yes No Business in the Home Yes No Type of Business How many occupants in the Home? 1 2 3 4 5 6 7 How far from Fire Department?mile(s)How far from Fire Hydrant?feet(s)Details for Condo (HO-6) Quote:Year BuiltName of Association Master Policy Deductible # of Units in BuildingCoverage Included for Betterments and Improvements? Yes No Unsure *****MUST obtain Certificate of Insurance from Company insuring Association******Number of Claims in Last 5 Years 0 1 2 3 Loss # 1 Details Loss # 2 Details Current CoveragesBuilding Personal Property Liability100K300K500K1MilMedicalkDeductibleLoss AssesmentkAmount of Betterments and ImprovementskEndorsementsIdentity Theft Yes No Sump Pump in Home Yes No Backup? Yes No Earthquake Coverage Yes No Sinkhole Coverage Yes No Scheduled Personal PropertyJewelry Guns Coins Silver/Goldware Computers Cameras Golf Equipment Furs Fine Arts CreditsCentral Burglar Alarm Yes No Company Fire Alarm Central Local Fire Extinguisher? Yes No Do you have Personal Umbrella? Yes No Limitmillion Fire Quoting - RentersCurrent Carrier Length of Time with CarrierLength of Time with Carrier -monthExpiration Date of policy MM slash DD slash YYYY Current Payment Method? Escrow Annual Monthly Cancelled or Non-Renewed in last 5 Years? Yes No Home under Construction? Yes No Swimming Pool on Premises? Yes No Fenced? Yes No Do you also have an Umbrella? Yes No Trampoline? Yes No Netted? Yes No Dogs at the Home? Yes No How many? 1 2 3 4 What Breed? Business in the Home? Yes No Type of Business How many occupants in the Home? 1 2 3 4 5 6 7 How far from Fire Hydrant?feetHow far from Fire Department?mile(s)Name of Fire Department? Details for Renters (HO-4) QuoteYear Built 20Year Built 19Year Built 18Name of Apartment Complex # of Units in BuildingNumber of Claims in Last 5 Years 0 1 2 3 Current CoveragesPersonal Property Loss of Use 1 Year 2 Years Fixed AmountLiability 100,000 300,000 500,000 1,000,000 Medical Payments 1000 2000 3000 4000 5000 10,000 Current Deductible 500 1000 1500 2000 2500 1/2% 1% 2% Any roomates? Yes No UntitledRoomate # 1: Name Date of Birth MM slash DD slash YYYY UntitledRoomate # 2: Name Date of Birth MM slash DD slash YYYY UntitledClaimsLoss # 1Date of Loss MM slash DD slash YYYY Loss AmountLoss Description Catastrophe Loss? Yes No EndorsementsIdentity Theft Yes No Earthquake Coverage Yes No Sinkhole Coverage Yes No Scheduled Personal PropertyJewelry Guns Coins Silver/Goldware Computers Cameras Golf Equipment Furs Fine Arts CreditsBurglar Alarm in Home? Yes No Company Fire Alarm? Central Local Fire Extinguisher? Yes No Deadbolts? Yes No General Liability / Business owners PolicyBusiness Name FEIN Effective DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Mailing Address Street Address City State / Province / Region ZIP / Postal Code Location Address (if different) Street Address City State / Province / Region ZIP / Postal Code Legal Form Sole Prop Partnership Corporation LLC Insurable Interest Owner Occupant Tenant Owner-Landlord Date Business Established MM slash DD slash YYYY Description of OperationsEstimated Sales in Current Year%Revenue from Service/Repair%Subcontractors Used? Yes No Certificates Obtained? Yes No Square Footage of Building to InsureYear BuiltConstruction of Building (Frame, Masonry, etc) Amount of Building Coverage Sought Protective Devices (Sprinkler, Security System, etc) - DescribeBusiness Personal Property Coverage DeductibleInland Marine Tools/Equipment Coverage Off Premises Computer Coverage Losses in last 5 Years Number of Officers & DirectorsD&O LimitDeductibleDo you carry Professional Liability? Limit of CoverageDo you have an employee handbook? Safety Handbook? Do you Carry Workers Comp? Have Vehicles to be Insured?
