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Florida First Home Quote

Please fill out as much of this form as possible. A detailed application helps us provide a more accurate quote. Some questions may be confirmed through consumer reports.

May we continue? Yes   No
Date
Current Client Yes   No
Applicant Information
Name
Occupation
Marital Status Married   Single
Date of Birth
Social Security #
Email
Phone Number(s)
Do you have any children? Yes   No
If Yes how many?
Location Information
Address
# of years you′ve been at this location
Is it your Primary Residence or a
Secondary Residence?
Is it Owner occupied, tenant occupied,
or VACANT?
Is property in a gated Community? Yes   No
Is it in a Subdivision? Yes   No
Name of gated Community or Subdivision
(if applicable)
Construction Classification
Foundation
Year Built
Heat/Cooled Sq Ft
Exterior Wall Finish
Number of Stories
Number of Baths
Paved road leading to residence? Yes   No
Floor Finish Information
Carpet %
Tile %
Vinyl %
Hardwood %
Heating and Air Information
Central heating and air (CHA)? Yes   No
Electrical Amperage?
Heat Electric? Yes   No
Is it permanently Installed? Yes   No
Update Year
Electric
Central Heat and Air
Plumbing
Roof
General Information (Part 1)
Roof
Roof Shape
Hurricane Shutters? Yes   No
If YES, is it open or enclosed?
Security System? Yes   No
Deadbolt Locks? Yes   No
Fire or Burglar Alarm? Yes   No
If YES, are they centrally monitored?
Yes   No
Smoke Detectors Yes   No
Fire Extinguisher? Yes   No
4 Point Inspection done? Yes   No
General Information (Part 2)
Fireplace? Yes   No
Woodstove? Yes   No
Any Decks? Yes   No
If YES, Sq Ft?
Any Porches? Yes   No
If YES, Sq Ft?
Any Screened Porch? Yes   No
If YES, Sq Ft?
Are there handrails? Yes   No
Garages? Yes   No
If Yes what type?
#of Cars kept in garage
Carports? Yes   No
Is there a fence on the property? Yes   No
If YES, how high or tall is the Fence?
If YES, is the gate "self latching"?
Yes   No
General Information (Part 3)
Sheds? Yes   No
If YES, number of Sheds
Need a Flood Quote? Yes   No
Do you have Elevation Certificate? Yes   No
If YES, please us a fax copy: 888-280-6602
If this is a newly purchased home or a refinance,
what is the Closing date?
Is there a Business on the premises? Yes   No
If YES, please explain
Do you have any Dogs? Yes   No
If YES, what Breed?
Horses/Farm animals? Yes   No
If YES, what Breed?
Pond nearby? Yes   No
Lake nearby? Yes   No
Sinkhole nearby? Yes   No
Coastal Water nearby? Yes   No
If YES: Distance from house?
Acreage?
General Information (Part 4)
Do you own any Recreational Vehicles
(such as golf carts, ATVs, or boats)? 		Yes   No
If YES, please list
Do you need a quote for Recreational Vehicle? Yes   No
Swimming Pool
Swiming pool at location? Yes   No
If YES, choose the type of pool
Does pool have a slide or diving board? Yes   No
Is the pool within a screened enclosure? Yes   No
Is the pool within a fenced yard? Yes   No
Past Homeowner Losses?
Date of loss?
Loss description
Amt paid?
Date of loss?
Loss description
Amt paid?
Date of loss?
Loss description
Amt paid?
Current Coverage
Current Carrier
Exp date
Current Premium
Reason for switching
Mailing Address (if different than insuring location address)
Co Applicant Information
Co Applicant
Occupation
Marital Status Married   Single
Date of Birth
Social Security #
Mortgagee
Contact name and #
Escrowed? Yes   No
Purchase Price
Desired Homeowners Coverages
Dwelling Coverage
All Perils Deductible
Hurricane Deductible
Do you have any collectables? Yes   No
Please list