Home Insurance Form
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1 - Homeowners Insurance Call 239-939-1010
In order to quote your new, or requote your existing, Homeowners Insurance, we will need the following information to accurately quote your coverage. We have over 21 companies writing home insurance in SW Florida, more than any other agent and we want to get you the absolute, rock bottom quote with every discount you qualify for. In order to do that, this information is necessary. If you can supply this information, I will immediately go to work for you.
ALL INFORMATION PROVIDED HERE WILL BE SENT to us SSL - SECURE SOCKET LAYER - ENCRYPTED for your security
Today's Date
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Name as on Deed
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Your Name (person completing this form)?
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Email (the one you want us to communicate with you).. WE DO NOT SELL OR SHARE THIS INFORMATION
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Who told you about us?
*
YOUR Date of Birth
(over age 50 discounts available)
*
MM
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SPOUSE Date of Birth
(over age 50 discounts available)
MM
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Daytime Phone
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Cell Phone
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Property Location you want to insure
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
If not a new purchase, how long have you lived at this residence?
Prior address if less than 6 months
Is the property currently Insured?
*
Please select
NO
YES
If currently insured, how much coverage are you carrying for the dwelling?
Amount of Replacement Cost coverage for contents
Deductibles
Hurricane 2%
Hurricane 5%
All Perils $500
All Perils $1,000
All Perils $2,500
Other
What date do you need this by?
MM
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DD
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Reason for shopping
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Is this a new purchase?
*
Yes
No
What company currently insures?
Are you under contract
If yes, Purchase Price?
Did you purchase as a Short Sale or a Foreclosure?
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Yes
No
Square footage under air
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Do you know the year it was built?
If yes, please provide year
Home Construction
*
Masonry Block
Frame (exterior walls)
Other
Type of roof
(ie: shingle, tile, etc.)
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# of stories
# of Bedrooms
# of Bathrooms
Are you Homesteaded at this address?
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Yes
No
What months is it OWNER occupied
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
ALL 12 MONTHS
NONE
What months Tennant occupied?
*
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
ALL 12 MONTHS
NONE
Name of Community
Please give us name of community if it has one
Protected Community?
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Gated
24 Hour Manned
Remote
Rovers
None of the Above
Central Station Monitored and activated Alarm System?
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Yes
No
Alarms
Burglar
Fire
Do you want a flood quote as well?
*
List animals owned
*
Dogs
Cats
Non-domestic
None
Breed & bite history
Is your home on acreage?
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Yes
No
Number of Acres
Do you have any of the following
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Swimming Pool
Trampoline
Diving Board/Slide
None
Pool Screened or Fenced?
Screened
Fenced
No Pool
Number of people living in home:
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Is this home for sale?
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Yes
No
Foreclosures, bankruptcies, or repossessions, last 5 years?
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Yes
No
ANY losses/claims at ANY location (reported or not) in the past 5 years?
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Yes
No
If yes, provide details, date, and amount paid:
Any Business conducted on premises
(ie: office, daycare, etc.)
*
Yes
No
Do you own any of the following?
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Cars insured in Florida
Watercraft
Motorcycle
ATV
Golf Cart
None
Attach copy of current policy (if available)
Attach copy of Wind Mitigation report (Need this for MAX discounts)
Who is your Auto Insurance Company?
*
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