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Home Insurance Application
Home Insurance Application
rootsins
2020-01-25T18:35:02-05:00
Home Insurance Quote
Named Insured
First Name
*
Last Name
*
Date of Birth
Gender
Male
Female
Employment
Engineer
Farm
Flagged Occupation
Homemaker
Military
Office, Sales
Professional Manager
Retired
Salaried
Scientist
Self-Employed
Skilled/Semi-Skilled
Student
Teacher/Professor
Unemployed
Unskilled
Other
Unknown
Occupation
Highest Level of Education
High School/GED
Associates
Bachelors
Masters
PhD
Law
Contact Information
Phone
*
Email
*
Home Address
Home Address
*
Home Address
Home Address
Home Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
How long have you lived at this address?
2 months or less
More than 2 months but less than 1 year
1 year or more
Prior Home Address
Prior Home Address
Prior Home Address
Prior Home Address
Prior City
Prior City
Prior State
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Prior State
Prior Zip
Prior Zip
Is there any other person listed on the home besides you (and spouse/partner, if applicable)
Yes
No
Additional Insured Name
Additional Insured Relationship to You
Additional Insured Date of Birth
Purchase date of home
Is the home currently insured?
Yes
No
New Purchase
Current Carrier
Current Annual Premium
Length of Time with Current Carrier
Less than 1 year
1-3 years
3-5 years
5-10 years
Greater than 10 years
Current Dwelling Coverage (Coverage A)
Closing Date
Purchase Price
Any home claims in the last 5 years?
Yes
No
Details
Deductible
$1,000
$1,500
$500
$2,500
$5,000
Amount you would be responsible to pay in the event of a claim
Type of Dwelling
Single Family Home
Two Family Home
Three Family Home
Four Family Home
Greater than a four family home
Style of Home
Ranch (1 Story)
Bungalow (1.5 Story)
Colonial (2 Story)
Bi/Tri-Level
Quad
Raised Ranch
2.5 Story
3 Story
Other (please describe in notes section)
Notes - Style of Home
Year Built
Square Footage (excluding basement)
Age of Roof
Less than 1 year old
1-5 years old
5-10 years old
10-15 years old
15-20 years old
20 years old or more
Foundation
Basement
Crawl Space
Slab
Type of Basement
Below Grade
Daylight
Walkout
Is the basement finished?
Yes
No
Percentage of basement finished
Exterior Walls
Vinyl Siding
Aluminum Siding
Brick Veneer
Brick/Masonry
Hardboard Siding
Wood Siding
Stone
Stucco
Mixture
Other (please explain in notes section below)
Notes - Exterior Walls
List details of each type of exterior wall covering (i.e. 20% vinyl siding, 80% brick)
Garage
2 Car Attached
2 Car Detached
1 Car Attached
1 Car Detached
3 Car Attached
3 Car Detached
4 Car Attached
4 Car Detached
Carport
Other (explain in notes section below)
Notes - Garage
Decks, Patios, Porches
Wood Deck
Brick Paver Patio
Cement Patio
Open Porch
Enclosed Porch
Screened Porch
Composite Deck
Other (explain in notes section below)
None of the above
Notes - Decks, Patios, Porches
Detached Items
Inground Pool
Above Ground Pool
Trampoline
Hot Tub
Shed
Pole Barn
Gazebo
Other (explain in notes section below)
None of the above
Notes- Detached Items
Number of Bathrooms
Quality of Bathrooms
Builders Grade
Semi- Custom
Custom
Designer
Basic
Quality of Kitchen
Builders Grade
Semi-Custom
Custom
Designer
Basic
Type of Heating System
Age of Heating System
Less than 1 year old
1-5 years old
5-10 years old
10-15 years old
15-20 years old
Over 20 years old
Do you have any fireplaces?
Yes
No
How many fireplaces?
Type of Fireplace
Gas
Natural
Both
Any woodburning stoves?
Yes
No
Air Conditioning
Yes
No
Window Units Only
Any animals in the home?
Yes
No
Details of animals in the home (type, breed, bite history)
Business operating in the home?
Yes
No
Details of business operating in home
Any jewelry, guns, furs or other collectibles that need to be insured?
Yes
No
Details of items (appraised value and brief description)
Would you like water back up coverage?
Yes
No
Limit:
$5,000
$10,000
$15,000
$20,000
$25,000
$50,000
Other (details in note section below)
Notes - Water Back Up Coverage
Any smokers in the home?
Yes
No
Do you have an alarm on the home?
Yes
No
What kind of alarm?
Burglar
Fire
Both
Local or Monitored?
Local (alarm chimes when doors open, etc.)
Monitored (reports to a monitoring company)
Home Insurance Payment Plan
Lienholder Billed (Escrow)
Monthly EFT
Monthly Bill
Semi-Annual
Annual
File Upload
Drop a file here or click to upload
Choose File
Maximum file size: 33.55MB
If you have access to your current declarations page, please upload (we also like to see photos of the home, appraisals and any other documents to help us properly insure your home!)
Signature
I warrant the above to be true and understand the insurance contract will be considered based on my warranty.
Electronic Signature
signature
keyboard
Clear
If you are human, leave this field blank.
Submit
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