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Next
Within the last 5 years, has the application experienced:
Foreclosure
Bankruptcy
Repossession
A lien Indictment for a crime
None of the above
Use of home
Primary
Secondary
Vacation
Rental
Short term rental
Vacant
Course of construction
Have you ever been declined for insurance?
Yes
No
Next
Do you want to add additional coverage?
Sewer and drain coverage ($50 year extra)
Extended replacement cost ($50 year extra)
Is the home a mobile home?
Yes
No
Does the home have knob and tube wiring?
Yes
No
Is the home on more than 200 acres?
Yes
No
Does the home have Polybutylene Plumbing?
Yes
No
Is the primary heat source a portable space heater?
Yes
No
Has the client had 4 or more claims in the past 3 years?
Yes
No
Next
Will there be any construction/renovations (Builder’s Risk) during this policy?
Yes
No
Any claims open with un-repaired damage?
Yes
No
Policy form?
Homeowners Insurance
Short Term Rental Homeowners Insurance
HO4 with Renters Insurance
Condo Insurance
Landlord Insurance
Rental Property Insurance
Vacant
Medical
Excluded
$1,000
$5,000 (additional premium)
Next
Liability coverage requested
$50,000
$100,000
$300,000
$500,000
$1,000,000
Excluded
Home Construction?
Frame
Brick
Stucco
Joint masonry/Concreate block
Milled log
Exotic (explain below)
Interior sprinkler
Full
Partial
None
Foundation
Slab (including basement)
Pier and beam (open)
Pier and beam (closed)
Stilts
Crawlspace
Other
Next
Alarm
Full
Partial
Both
None
Roof
Asphalt
Wood shake
T-Lock
Tar/gravel or rubber
Dimensional shingle/hail rated
Title
Metal
Other (explain below)
Wiring
Circuit breaker
Fuses
Aluminum
Other
No wiring
Plumbing
Copper & PVC & PVX
Polybutylene
Galvanized
No plumbing
Other (explain below)
Roof condition
Excellent
Good
Average
Below average
Next
Type of building
Single family
Duplex
Triplex
4-Plex
Condo
Townhouse
Heating
Central heat/radiator
Electric base board
Wood stove
Space heater
No heat
Day care at the home?
Yes
No
Next
Any lakes ponds on the property?
Yes
No
Is there a wood stove on the premises?
Yes
No
Is the dwelling on a National Historic Register?
Yes
No
Are there animals on the premises?
Yes
No
Do you want dog liability?
Yes
No
Is there a swimming pool?
Yes
No
Is it fenced? (pool)
Yes
No
Next
Any business operating from the home (home based)?
Yes
No
Any claims in the past 3 years? If yes, I need the below for each claim
Yes
No
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Thank You!
