|
PERSONAL INFORMATION
|
|
Name:
|
|
|
Property Address:
|
|
|
Unit #:
|
|
|
City:
|
|
|
State:
|
|
|
Zip Code:
|
|
|
Day Phone #:
|
ext.
|
|
Evening Phone #:
|
ext.
|
|
Cell Phone #:
|
|
|
Email Address:
|
|
|
Best time to call:
|
|
|
Best way to reach you:
|
|
|
How did you hear about us:
|
|
|
CURRENT INSURANCE POLICY INFORMATION
|
|
Insurance company:
|
|
|
Policy #:
|
|
|
Policy expiration date:
|
/
/
|
|
Annual premium:
|
$
|
|
Are you being Non-Renewed or Cancelled:
|
|
|
If yes, reason for NR or Cancelled:
|
|
|
"Coverage A - Dwelling Coverage" limit on policy:
|
$
|
|
"Coverage C - Contents Coverage" limit on policy:
|
$
|
|
All Other Perils ("AOP") deductible:
|
|
|
Does your current policy include or exclude
wind, hail and hurricane coverage:
|
|
|
If your policy does include wind and hurricane
coverage, what is your Hurricane deductible:
|
|
|
|
|
Name of condo association:
|
|
|
Occupancy:
|
|
|
Dwelling use:
|
|
|
Type of dwelling:
|
|
|
Year built:
|
|
|
Living area square feet:
|
|
|
Number of stories:
|
|
|
Construction type:
|
|
|
Roof type:
|
|
|
Shape of roof:
|
|
|
Age of roof:
|
Years
|
|
UNDERWRITING QUESTIONS
|
|
Is the condo currently for sale:
|
|
|
Is your condo in a Flood Zone:
|
|
|
Do you own an ATV or boat:
|
|
| |
|
Filed any claims in the past 5 years:
|
|
|
If yes, describe the claim:
|
|
|
How much was paid:
|
$
|
| |
|
Age of Hot Water Heater:
|
Years
|
|
Age of Washing Machine Hose:
|
Years
|
| |
|
Do you have a "monitored" alarm system:
|
|
|
Do you live in a gated community:
|
|
| |
|
Do you have or intend to have any
dog(s) on the premises:
|
|
|
If yes, what breed is the dog(s):
|
|
| |
|
Do you have or intend to have any
non-domesticated animals on the premises:
|
|
|
If yes, what type are the animals:
|
|
| |
|
Do you conduct any business on the property:
|
|
|
If yes, what type of business:
|
|
| |
|
Have you and/or your spouse had a bankruptcy, lien,
foreclosure, or repossession in the past 5 years:
|
|
|
Have you and/or your spouse been convicted
of a felony in the past 10 years:
|
|
|
Have you and/or your spouse had your driver's
license suspended in the past 5 years:
|
|
|
Have you been involved in a lawsuit against an Auto or
Homeowner's insurance company in the past 5 years:
|
|
|
Have you been arrested for DUI, assault and battery
or disorderly conduct in the past 10 years:
|
|
|
|
