Homeowners Insurance Application

    1. Vesting/Ownership name (Name as it will appear on policy) (required)

    2. Address (required):

    3. Contact Email Address (required)

    4. Contact Phone:

    5. Year property was built:

    6. Square footage (habitational area only, not garage)


    7. Construction type (steel frame & stucco, wood frame & stucco, masonry, wood siding, etc)

    8. Number of Stories:


    9. Pool or Spa:


    10. Style:

    11. Number of Bathrooms:


    12. Any fireplaces:


    13. Type of roof (comp single, tar & grave, wood shake, etc):

    14. Insured Date of Birth:


    15. Co-insured Date of Birth

    16. If dwelling is over 25 years old, please list any upgrades done (plumbing, electrical, heating, roof, etc):

    17. If dwelling was built prior to 1980, is it bolted to the foundation

    18. Is the water heater strapped?

    19. What type of heating system do you have (central forced air, etc)

    20. Do you have a garage?

    21. If yes, attached or detached

    22. a) Sq. ft of garage

    b) Number of cars in garage

    23. Do you have any pets? If yes, what type/breed

    24. Do you have any of the following protective devices? (select all that apply):

    Central Station Fire Alarm

    Central Station Burglar Alarm

    Local Fire Alarm

    Local Burglar Alarm

    Security Doors

    Battery Operated Smoke Detectors

    Hard Wired Smoke Detectors

    Fire Sprinklers

    Fire Extinguishers

    Dead Bolt Entries

    25. Is home in a gated community? 26. Date home purchased:

    27. Number of prior residences with in the last 3 years?

    28. Prior address if less then 3 years at the current address

    29. Current building value (from your existing policy, if applicable):

    30. Current Insurance Carrier:

    31. Current policy expiration date:

    32. Approximate distance from the nearest fire hydrant:

    33. If applicable, list lender's name, address, and a loan number:

    34. Have you had any claims in the past 5 years? If yes, describe the losses and list the amounts paid

    35. Have you had an insurance canceled or declined in the last 3 years? If yes, describe:

    36. Do you have any jewelry and/or fine arts that need to be added to the coverage (scheduled)?
    If yes, describe:

    37. Do you have a business operation that is run from your home? If yes, describe