First Name Last
Name
Property
Address 1:
Property Address 2:
City,
ST Zip:
State
FL
GA
NC
NY
SC
If you do not see the
state, we
are not writing in your area at this time, but we are adding new
states.
County
Home Phone:
Work
Phone:
Fax Number:
E-Mail Address
How Did you hear about us?
Select One
Referral
Yellow Pages
Post Card
Newspaper
FMAP
Current Client
Other
If
referral please provide name we send like to thank you to anyone who refers us
clients
Do you
have current homeowners insurance coverage or this a new closing?
Yes
New
If not a new purchase what is
your renewal date?
How long have you been with your
current insurance company?
Please
describe any homeowners/renters claims you have made in the last 5
years.
Claim
Type:
Select One
Water Damage
Smoke Damage
Fire Damage
Wind Damage
Other
Amount ($):
Select One
under $1,000
$1,000-$2,500
$2,500-$5,000
over $5,000
not sure
Date
Select One
Water Damage
Smoke Damage
Fire Damage
Wind Damage
Other
Amount ($):
Select One
under $1,000
$1,000-$2,500
$2,500-$5,000
over $5,000
not sure
Date
Claim Type:
Select One
Water Damage
Smoke Damage
Fire Damage
Wind Damage
Other
Amount ($):
Select One
under $1,000
$1,000-$2,500
$2,500-$5,000
over $5,000
not sure
Date
How would you like us to send you
the quote?
Select One
Phone
Fax
Email
Mail
What Insurance Companies have you
received quotes from?
Select
the type of insurance coverage you require:
Select One
ho-3 single family home
ho-4 Apartment
Ho-6 Condo or Townhouse (SEE NOTE)
DF-Investment property
Ho-6 Condo or Townhouse (Do not need
to insure outside of structure, if you do please use HO-3)
General Info
Do
you have pets?
Yes*
No
*If
you own any dogs we need breed name(s) and any bite history?
Please
estimate the total living area square footage of the residence
(living area only):
Year Built (Required)
What
is the total number of floors, excluding the basement:
Select One
1
2
3
4
5+
What
is the number of bathrooms?
Select One
1
1 1/2
2
2 1/2
3
3 1/2
4
4 1/2
5+
Is
there a garage?
Yes
No
Please
describe the garage:
Select One
Attached to Home
Not Attached to Home
If
your home has a garage, how many vehicles does it hold?
Select One
None
1
2
3
4
5+
Please
describe the exterior walls of structure:
Select One
Cinder Block
Frame
Other
Not Sure
Describe
the type of roof on the home:
Select One
Asphalt
Colored Granules (Common)
Wood ShakeTreated Wood Slats
Tile or Clay Shingles(Spanish Roof)
Metal
Flat Roof
Other
Not Sure
How old is the roof?
Is any part of the roof flat?
Select One
Yes
No
If yes how much of the roof
Do you have a screen in patio?
Select One
No-Screen in Patio
Yes-Screen in Patio
If yes what is the square footage
Is
your home located within 1,000 feet of a fire hydrant?
Yes
No
Do you
have a pool and is it screened in or fenced in?
Yes-
Fence
Yes-
Screen In No Pool
Do
you have a trampoline?
Yes
No
Have
you had the windstorm mitigation form filled out?
If yes please answer the questions below in
red. If "No" please skip the red questions.
Yes
No
Florida Homeowners Insurance Policies Only
Wind Mitigation Form
Questions Only i f
you have not had the windstorm mitigation form filled out please
consider you can save up to 50% of your premium. You can order a
free inspection by calling The My Safe Florida Home Program at 1-866-513-6734
Roof Covering
Unknown
Meets 2001 Code
Does not Meet
Roof Deck Attachment
Unknown
Class A
Class B
Class C
Roof to Wall Attachment
Unknown
Clips
Single Wraps
Double Wraps
Structural
Roof Geometry
None
Hip Roof
Other
Gable End Bracing
Unknown
Gable End Not Braced
Gable End Braced
Secondary Water
Resistance
None
SWR
No SWR
Opening Protection
None
Hurricane
Basic
Not Rated
Wood Panels
Do you live in a gated community?
None
Gated and Security 24 Hours
Gated no Security
Is the
property East or West Of I-95? (Florida Only)
East
West
Is
your home protected by a security system, What type?
Select One
None
Sounds Alarm not central
Central Burglar Alarm no Fire Alarm
Central Burglar Alarm with Fire Alarm
length
of occupancy (months per year)?
Requested
deductible:
$
Select One
100
250
500
1000
2500
Not Sure
Requested
liability coverage:
$
Select One
300,000
500,000
1 Million Umbrella
How
much do you want to carry for your dwelling coverage?
$
Would
you like a flood insurance quote?
Yes
No
Would you like a umbrella insurance quote?
Yes
No
Do you
need golf cart coverage?
Yes
No
If this is a apartment, condo or
townhouse and you do not need to insure the outside structure how
much personal property do you want a quote on?
$
