My Homeowners Quote Questionnaire

Thank you for the opportunity to earn your business!

While it is typically fastest to set up a time to talk together and gather your home details, we understand that every person is different and sometimes our schedules don't align.

The good news is, we can still help you!

Let's Get Started!

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1Policyholder Info

2Location Information

3Home Information

4Inspection(s)

5Current Info

6Thank you!

Primary Policyholder Information

Full Name*

Date of Birth*

Phone*

Your Email*

Is there a secondary policyholder we need to list?*

Secondary Policyholder Information

Secondary Policyholder Full Name*

Date of Birth

Location Information

Tell us where this home is located and how you will use it. Feel free to include any details you think are important.

Address*

Is this home a new purchase for you?*

Congratulations! When is your closing date?

We don't know yet

What is your purchase price of the home?

Is this your primary home?*

If not your primary residence, tell us how you will occupy this home.*

If your secondary/vacation home, how many months will it be occupied per year?*

Do you have at least a three night minimum stay?*

Any other details you think we may find helpful?

Details About Your Home

We are able to pull a majority of the information on your home and surroundings from the local Property Appraiser's website in order to generate a preliminary quote. We want to be sure information is as accurate as possible to avoid any unexpected price increases. You will have a chance to review the information when reviewing your quote. Please complete this section as thoroughly as possible. If you need to leave a field blank, we will have the chance to review it together!

What type of home are we quoting for you?*

Is the home block or frame construction?*

How many bedrooms?*

How many full bathrooms?*

How many half bathrooms?

What year was the home built?

What is the square footage?

How many stories is your home?

What type of roof is on the home?*

What year was the roof replaced?*

If the roof is original to the home, enter the year the home was built.

If your home is more than 20 years old, have there been any updates to the AC, water heater, or electrical?

Please explain any updates:

Do you have any of the following? Check all that apply:

Fireplace

Pool

Screened Porch/Enclosure

Shed

Trampoline

Do you have a detached garage or carport?

What type of flooring is in the interior of the home?*

Do you operate a business from this location?*

If yes, explain:

Have there been any claims on this home in the last 5 years?

Please explain claim information:

Date of loss, type of claim, and insurance payment amount

Do you have any pets?*

Breed type(s), # of animals, etc.

Lets get some more information about your pool!

Do you have a diving board or waterslide?*

Is there a screen enclosure or fence around your pool area?*

Current Insurance Information

Do you currently have insurance for this home?*

Which carrier are you currently with?*

When does your current policy expire?

Is this policy being non-renewed?

Gotcha! We'll just need to provide some information on the lapse in coverage. We'll need to know how long the property has been without coverage and a quick description of the reason for the carrier.

Personal Financial Information

We know it's personal. This information will only be used to secure your quote with our carriers and will remain confidential - even if we don't become your agent!

Have you had any bankruptcies, repossessions, foreclosures, or liens in the last 5 years?*

Have you been at this address for less than 5 years?*

Prior Mailing Address