New Client Information

Comprehensive Information Form Includes Applicant information, Property Information, Risk Information, Update Information, Mortgage/Lender Information, Prior Insurance Information, and Misc. Info

Applicant's Name(Required)

First Last

Home/Cell Phone(Required)

Work Phone

Email(Required)

Occupation

Marital Status(Required)

DOB(Required)

Referred By:(Required)

Co-Applicant's Name

First Last

Home/Cell Phone

Work Phone

Occupation

Marital Status

DOB

Property Information

Risk Address(Required)

Street Address Address Line 2 City State ZIP Code

What kind of insurance are you looking for?(Required)

Auto

Boat

Business Owners Package

Home/Condo/Renters

Motorcycle

Rental Property

Umbrella

Type of Residence(Required)

Primary

Secondary

Tenant

Builder’s Risk – Renovation

Builder’s Risk – New Construction

Vacant

Mailing Address(Required)

Same as previous

Street Address Address Line 2 City State ZIP Code

Previous Address (If longer than 3 years since change of residency)

Street Address Address Line 2 City State ZIP Code

Risk Information

Year Built:(Required)

Living Square Footage:(Required)

# of Stories:(Required)

# of Bedrooms:(Required)

# of Bathrooms:(Required)

# of Families:(Required)

Single

Duplex

Triplex

4-plex

Condo

Townhome – End Unit

Townhome – Interior Unit

If Condo, # of Floors in Building:(Required)

If Condo, # of Floor Unit is On:(Required)

If Condo, Sprinkler System within Unit?(Required)

Foundation:(Required)

Slab

Crawl Space Open

Crawl Space Closed

Basement

Piers

If Open Crawl Space:

Lattice/Slats

Brick (Perm)

Rails?(Required)

Rails Across Porch?(Required)

Rails On Front Steps?(Required)

Rails On Back Steps?(Required)

Exterior Construction Type (must equal 100%)

% Brick

% Wood

% Vinyl

% Hardiplank

% Other (Please list: Aluminum, Asbestos, Metal, Stuco-Eifs, Stuco-Traditional, Wood Shakes)

Roof Shape (must equal 100%)

% Hip

A hip roof is a roof design where all sides slope downwards from a central ridge or point, creating a “pyramid-like” shape with no vertical ends.

% Gable

A gable roof has a simple, triangular shape with two sloped sides that meet at a central ridge.

% Flat

% Other

Garage:

Attached

Detached

Carport:

Attached

Detached

Kitchen:

Basic

Builder’s Grade

Semi-Custom

Custom

Bathroom 1:

Basic

Builder’s Grade

Semi-Custom

Custom

Bathroom 2:

Basic

Builder’s Grade

Semi-Custom

Custom

Bathroom 3:

Basic

Builder’s Grade

Semi-Custom

Custom

Bathroom 4+ (Please list separated by commas)

Flooring (must equal 100%):

% Wood

% Tile

% Carpet

% Laminate

% Other

Additional Property Characteristics(Required)

None

Porch

Patio

Deck

Porch Size (sq. ft.)

Patio Size (sq. ft.)

Deck Size (sq. ft.)

Covered?

Screened Enclosure?

Aluminum?

Detached Structures:(Required)

None

Shed

Guest House

Pool House

Other

If Other, Please List:(Required)

Additional Property Characteristic Notes:

Monitored Fire Alarm:(Required)

Monitored Theft Alarm:(Required)

Alarm Company:

Dead Bolts:(Required)

Fire Extgshers:(Required)

Fireplace:

Solar Panels:(Required)

Solar Panels:

Owned

Leased

# of Solar Panels:

Pool:(Required)

Diving Bd/Slide:

Fence:

Does fence have locking mechanism? (i.e. padlock, combination lock):

Property within 300 ft. of Commercial Business?(Required)

Please describe the Commercial Business:

Trampoline?(Required)

Burglar Bars?(Required)

If yes, are burglar bars quick release?

Dog(s)?(Required)

Breed(s):

If yes, Bite History?

If yes, Details of Incident(s):

Update Information:

A/C:(Required)

Central

Window Unit

A/C Updated/Replaced:

Full

Partial

A/C Year Updated/Replaced (Paid in Full. Receipts will be required.):

Heat:(Required)

Gas

Electric

Heat Updated/Replaced:

Full

Partial

Heat Year Updated/Replaced (Paid in Full. Receipts will be required.):

Electric:(Required)

Circuit Breaker

Fuse

Electric Updated/Replaced:

Full

Partial

Electric Year Updated/Replaced (Paid in Full. Receipts will be required.):

Plumbing:(Required)

Cop.

PVC

Galv.

Pex

Plumbing Updated/Replaced:

Full

Partial

Plumbing Year Updated/Replaced (Paid in Full. Receipts will be required.):

Water Heater:(Required)

Tank

Tankless

Water Heater Placement:(Required)

Water Heater Updated/Replaced:

Water Heater Year Updated/Replaced (Paid in Full. Receipts will be required.):

Generator:(Required)

Roof:(Required)

Roof Updated/Replaced:

Full

Partial

Roof Year Updated/Replaced (Paid in Full. Receipts will be required.):

Mortgage/Lender Information

Mortgage Information:(Required)

None

New Purchase

Insurance Escrowed

Insured Pay

Lender/Contact:

Closing Date

Prior Insurance Information (Required if not New Purchase)

Flood Insurance:(Required)

Flood Zone:

Elevation Certificate:(Required)

Carrier:

Policy #:(Required)

Effective Date:(Required)

Home Insurance (If Yes, prior Dec. page required for binding.):(Required)

Carrier:(Required)

Policy #:(Required)

Effective Date:(Required)

Premium:(Required)

Dwelling Coverage:(Required)

Contents Coverage:(Required)

Liability:(Required)

Deductible:(Required)

Loss History: Any loss on any property owned in the last 5 years.(Required)

Details:

NEW CLIENT INFORMATION FORM