Homeowners Quote Form "*" indicates required fields Step 1 of 4 25% Agency InformationAgency* Agency Contact* Agency Phone*Agency Email* Primary Insured InformationPrimary 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Insured Risk Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Insured InformationSecondary 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 InformationName 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 No Does the LLC engage in business activities other than real estate?* Yes No Is the risk a time-share split between the principles of the corporation, LLC, or LLP?* Yes No Loss HistoryNumber of prior losses within the past 3 years*(Please add additional loss details fields below as necessary.)None1 Loss2 Losses3 LossesDate 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 DetailOccupancy Type*PrimarySecondaryAnnual RentalShort-Term RentalVacantBuilder's RiskIs there a mortgage on the property?* Yes No Is the insurance escrowed into the mortgage??* Yes No 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 No Are the circuit breakers Stab-Lok, NOARC, Zinsco, Challenger, Square D, or GTE Sylvania?* Yes No Type of Roof* Shingle Architectural Shingle Concrete/Clay/Slate Tiles Wood Metal Tar & Gravel Year Roof Was Updated* Do you have Solar Panels?* Yes No Do you have a Wind Mitigation Certificate?*(If yes, you may use document upload field at end of form) Yes No Do you have a 4 Point Inspection document?*(If yes, you may use document upload field at end of form) Yes No Alarm System - Central Station Fire Alarm* Yes No Alarm System - Central Station Burglary Alarm* Yes No Is there a pool?* Yes No Is pool fenced / screened?* Yes No Are there any animals with a bite or attack history?* Yes No Bancruptcy, Foreclosure. Repossession, Arson, Fraud, or Other crime related to property loss within the past 5 years?* Yes No Is any business (childcare or other) conducted on the premises?* Yes No Please specify the type of business conducted on premises.* Has there been a lapse in coverage?* Yes No 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 OnlyDoes Vacant and Builder's Risks apply to your property?*If yes, a number of applicable fields will appear. Yes No 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 No Does the contractor have a CGL policy of at least $1M?* Yes No Has construction started?* Yes No Is the property locked, fenced, or boarded?* Yes No Detailed Description of Renovations*Is property HO-6 / Condo?*If yes, a number of applicable fields will appear. Yes No Number of Stories in the Condo Building* Floor that the Condo Unit is Located On* Limits/Coverages/DeductiblesDwelling 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*None$100 K$300 K$500 K$1 MMedical Payments*None$1 K$2 K$3 K$4 K$5 K$10 KWater Back-Up*$5 K$10 K$25 KLimited Mold*$5 K$10 K$15 KEffective 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 Select files Accepted file types: pdf, doc, docx, xls, xlsx, jpg, gif, odt, ppt, pptx, jpg, Max. file size: 5 MB.