Agent To Send Data To
Full Name
Address Of Primary Property
Date of Birth
Why Are We Having A Conversation?
The Named Insured Is An
Email
Phone
Marital Status
Is the mailing address different from the primary residence?
Occupancy & Former Occupations
Does the applicant have a high-profile occupation?
Discount — Military / First Responder?
Is Anyone Else On The Deed?
Other Household Members (Not On The Deed)
Has the applicant had a judgment or lien in the past 5 years?
In the last 5 years, has any applicant been indicted for or convicted of fraud, bribery, arson or an arson-related crime?
Has any coverage been declined, cancelled, or non-renewed during the last 3 years?
Have they lived at the same address for the last 3 years?
Property Address
Distance to Coast
Type of Property
Occupancy Type
Is the home for sale?
Square Footage
Year Built
Number of Stories
Number of Bedrooms
Number of Bathrooms
Type of Construction
Architectural Style
Is it a modular, earth, dome, green/experimental, or other non-conventional home?
Is the dwelling recognized as a historical building?
Condition of Home
Renovation & Construction
Any remodeling/renovation plans in the next 12 months?
Is the property situated on more than one acre?
Slope of Site
Foundation Type
Exterior Materials (%)
Flooring Materials (%)
Roof Age
Roof Type
Roof Shape
Year Roof Last Replaced / Renovated
Solar Panels
Electrical System
Year Electrical Last Renovated
Any knob & tube wiring, aluminum wiring, or fuses?
Any electrical panels by FPE, Stab-lok, Challenger, Pushmatic, Sylvania, or Zinsco?
HVAC
Year HVAC Last Renovated
Heating
Fireplace(s)
Wood-Burning Stove or Portable Heating Device?
Is there an above-ground fuel tank on the premises?
Is there an underground fuel tank on the premises?
Plumbing
Year Plumbing Last Renovated
Any galvanized, cast iron, polybutylene, PEX (pre-2006), or other non-copper/PVC piping?
Does the dwelling have any piping that is not copper, PVC, and/or PEX?
Water Heater Location
Water & Sewage
Garage Type
Separate Structure(s) — value of detached garages, gazebos, fences, walls, gates, sheds, driveways, etc.
Pool
Fire Alarm
Smoke Detector
Fire Extinguisher
Sprinkler System
Miles to Fire Department
Feet to Hydrant
Burglar Alarm
Water Alarm
Deadbolt Locks On All Exterior Doors
Gated / Secured Community
Tree-Free Yard (no trees over 10 ft within 20 ft of the home)?
Property-level Fire Mitigation?
Community-level Fire Mitigation (e.g. Firewise)?
HOA
Number of Mortgages On The Property
Does the home have any existing (non-cosmetic) damage?
Is there any structural damage to the dwelling?
Has the home been in foreclosure in the last 3 years?
Any business or farming conducted on premises?
Animals on Property
Is there an ADU (Accessory Dwelling Unit) on the property?
Any loss or claim on this property in the past 5 years?
List of Drivers To Be Covered
List of Cars, Boats, & Other Vehicles