Homeowners Insurance

Contact info: Name of Owner Phone Number: Fax: Email: How Did you hear about us? Referral Yellow Pages Post Card Newspaper Other     If referral please provide name we send like to reward anyone who refers us clients Property Location: Address: City: State: Zip: County: Have you had any claims in the last 3 years? General Information: Is the home currently insured? yes no How many months do you occupy the home? _ 3-6 months 7-9 months 10-12 Is this a rental property? yes no Is anyone in the household older than 55 years old? yes no Is this a new purchase? yes no Dwelling Information: Current Coverage Amount or Replacement Cost of dwelling: Construction Type: Home Condo Townhouse What is the Year Built? How many Square feet is the home? [Under air, living area only]: How many Stories is the home? 1 2 3 4 or more Construction Type: CBS Frame MNC (3 or more stories) Roof Type: tile shingle flat metal tar and gravel How Old is the Roof?   Current Insurance Information: Current Insurance Company: When does your policy expire? Expiration Date: Would you like a flood insurance quote? Comments/Questions Home specifics: How many bathrooms? Attached Garage? yes no If yes, number of cars: Do you have a screen in patio? If yes please provide square footage Is there a swimming pool? yes no If yes, is it screened or fenced? yes no If  a condo, do you have fire sprinklers inside the unit? yes no Do you have an central burglar alarm? yes no Do you have fire hydrant within 500 feet from the location? yes no Do you have an golf cart? yes no Do you have an central fire alarm? yes no Is your home located in a Gated and or Guarded community? yes no Condo and Apartments only? How much Personal Property Coverage? Do you have a dog? If yes what type? Windstorm Mitigation Information: Have you had a Windstorm Mitigation Inspection completed? yes no If Yes please answer the questions below?     Roof Cover Non FBC Equivalent FBC Equivalent Reinforced Concrete Roof Deck Level A Level B N/A Roof Shape Flat Hip Gable N/A Roof Deck Attachment A - 6d @ 6 inch by 12 inch B - 8d @ 6 inch by 12 inch C - 8d @ 6 inch by 6 inch Wood Deck - Type II only Metal Deck - Type II or III Reinforced Concrete Roof Deck Opening Protection Class A Class B Class C None Roof-Wall Connection Toe Nails Clips Single Wraps Double Wraps None Secondary Water Resistance yes no Agent Use Only Agent Use Only chm rtm bs cp kb rl mw cm