form - Island Breeze Insurance

Homeowners Quote Form

This quote is a non-binding price indication that is subject to a signed application, confirming additional information, and approved from our office. No coverage is bound until confirmed by our office.
For assistance with form, call Lisa J. Doran, Vice president, Island Breeze Insurance at (888)-590-9215 or cell (570)-449-9772.

"*" indicates required fields

Step 1 of 4

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Agency Information

Agency*

Agency Contact*

Agency Phone*

Agency Email*

Primary Insured Information

Primary Insured Name*

First Last

Primary Insured Date of Birth*

MM slash DD slash YYYY

Primary Insured Phone*

Primary Insured Occupation*

Primary Insured Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary Insured Risk Address*

Street Address Address Line 2 City State ZIP Code

Secondary Insured Information

Secondary Insured Name

First Last

Secondary Insured Date of Birth

MM slash DD slash YYYY

Are you an LLC, Trust or Estate?*

No, I am an individual

Yes, this is an LLC, Trust or Estate

LLC/Trust/Estate Information

Name of LLC/Trust/Estate*

Entity Type*

LLC/LLP/Corporation

Trust

Estate

Name of Primary Principal/Trustee/Executor*

First Last

Primary Principal/Trustee/Executor Date of Birth*

MM slash DD slash YYYY

Are there more than 5 unrelated principals?*

Yes

Does the LLC engage in business activities other than real estate?*

Yes

Is the risk a time-share split between the principles of the corporation, LLC, or LLP?*

Yes

Loss History

Number of prior losses within the past 3 years*

(Please add additional loss details fields below as necessary.)

Date of Loss 1*

MM slash DD slash YYYY

Description of Loss 1*

Amount Paid - Loss 1*

Status of Loss 1*

Open

Closed

Check box if you need to add loss 2 detail fields

I need to add loss 2 details

Date of Loss 2*

MM slash DD slash YYYY

Description of Loss 2*

Amount Paid - Loss 2*

Status of Loss 2*

Open

Closed

Check box if you need to add loss 3 detail fields

I need to add loss 3 details

Date of Loss 3*

MM slash DD slash YYYY

Description of Loss 3*

Amount Paid - Loss 3*

Status of Loss 3*

Open

Closed

Risk Detail

Occupancy Type*

Is there a mortgage on the property?*

Yes

Is the insurance escrowed into the mortgage??*

Yes

Requested Form

(This is applicable if form is completed by an agent.)

HO-3

HO-5

HO-8

DP-1

DP-3

HO-6

How is the property deeded?*

(example - your name, LLC name, etc.)

Year Built*

Construction Type*

Square Footage*

Number of Stories*

Number of Families*

Protection Class*

Distance to Fire Station in Miles*

Distance to Fire Hydrant in Feet*

Heating Sysyem*

Electric

Oil

Gas

Woodstove

Space Heater

Year Heating System Was Updated*

Was Heating System Update Partial of Full*

Partial Heating System Update

Full Heating System Update

Plumbing Sysyem*

Copper

PVC

PEX

Galvanized

Polybutylene

Lead

Year Plumbing System Was Updated*

Was Plumbing System Update Partial of Full*

Partial Heating System Update

Full Heating System Update

What year was the water heater last replaced?*

Electrical - Type of System*

Circuit Breakers (Greater than 100 amps)

Circuit Breakers (Less than 100 amps)

Fuses

Year Electrical System Was Updated*

Was Electrical System Update Partial of Full*

Partial Heating System Update

Full Heating System Update

Does System Include Knob & Tube, Cloth, or Aluminum Wiring?*

Yes

Are the circuit breakers Stab-Lok, NOARC, Zinsco, Challenger, Square D, or GTE Sylvania?*

Yes

Type of Roof*

Shingle

Architectural Shingle

Concrete/Clay/Slate Tiles

Wood

Metal

Tar & Gravel

Year Roof Was Updated*

Do you have Solar Panels?*

Yes

Do you have a Wind Mitigation Certificate?*

(If yes, you may use document upload field at end of form)

Yes

Do you have a 4 Point Inspection document?*

(If yes, you may use document upload field at end of form)

Yes

Alarm System - Central Station Fire Alarm*

Yes

Alarm System - Central Station Burglary Alarm*

Yes

Is there a pool?*

Yes

Is pool fenced / screened?*

Yes

Are there any animals with a bite or attack history?*

Yes

Bancruptcy, Foreclosure. Repossession, Arson, Fraud, or Other crime related to property loss within the past 5 years?*

Yes

Is any business (childcare or other) conducted on the premises?*

Yes

Please specify the type of business conducted on premises.*

Has there been a lapse in coverage?*

Yes

If yes, what was the last date of coverage?*

Check any Scheduled items on your policy*

None

Jewelry

Furs

Guns

Collectables

Others

Do you have any recreational vehicles?*

None

Motorcycles

Boats

ATVs

Golf Carts

Snowmobiles

Vacant and Builder's Risks Only

Does Vacant and Builder's Risks apply to your property?*

If yes, a number of applicable fields will appear.

Yes

Purchase Date*

MM slash DD slash YYYY

How long has the risk been vacant?*

Purchase Price*

Intended Use of Building*

Renovation Type*

Cosmetic

Structural

Cost of Renovations*

Is work being performed by a licensed contractor not affiliated wit the insured?*

Yes

Does the contractor have a CGL policy of at least $1M?*

Yes

Has construction started?*

Yes

Is the property locked, fenced, or boarded?*

Yes

Detailed Description of Renovations*

Is property HO-6 / Condo?*

If yes, a number of applicable fields will appear.

Yes

Number of Stories in the Condo Building*

Floor that the Condo Unit is Located On*

Limits/Coverages/Deductibles

Dwelling Value*

Other Structures Value*

Are values above Replacement Cost Value or Actual Cash Value?*

RCV (Replacement Cost Value)

ACV (Actual Cash Value)

Personal Property Value*

Is Personal Property Value at Replacement Cost Value or Actual Cash Value?*

RCV (Replacement Cost Value)

ACV (Actual Cash Value)

Loss of Use*

Liability Coverage*

Medical Payments*

Water Back-Up*

Limited Mold*

Effective Date*

MM slash DD slash YYYY

Term in Months*

AOP Deductible (All Other Perils)*

Wind Deductible*

Is the insured interested in any of the following coverages?

(select all that apply)

Flood

Personal Umbrella

Identity Theft

Earthquake

Auto (please upload current declaration if quote requested)

Document Upload

(Use this to upload any requested inspection certificates, certifications or auto declarations.)
Allowable file types: pdf, doc, docx, xls, xlsx, jpg, gif, odt, ppt, pptx, jpg. Maximum 10 files at 25mb.

Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, jpg, gif, odt, ppt, pptx, jpg, Max. file size: 5 MB.