X/TwitterThis field is for validation purposes and should be left unchanged.Applicant InformationWhat Applicant Entity type owns this property?(Required) Individual Trust Trust Name:(Required)Full Name:(Required) First Last Trust Owner's Full Name:(Required) First Last Date of Birth:(Required) MM slash DD slash YYYY Trust Owner's Date of Birth:(Required) MM slash DD slash YYYY Gender:(Required) Male Female Trust Owner's Gender:(Required) Male Female Marital Status:(Required) Single Married Divorced Widowed Trust Owner's Marital Status:(Required) Single Married Divorced Widowed Spouse Full Name:(Required) First Last Owner's Spouse Full Name:(Required) First Last Spouse Date of Birth:(Required) MM slash DD slash YYYY Spouse Gender:(Required) Male Female Owner's Spouse Date of Birth:(Required) MM slash DD slash YYYY Owner's Spouse Gender:(Required) Male Female Mailing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:(Required)Email Address:(Required) Inspection Contact:(Required)Applicant Occupation:(Required)Trust Owner's Occupation:(Required)Why was the Trust formed?(Required)(e.g., Tax Purposes, Real Estate Investments, Asset Protection, etc.)If the trust has been engaged in any form of business, please explain:(Required)(N/A if not applicable)If the Trust owns any other properties, please list here:(Required)(N/A if not applicable)Is the Trust a "Land Trust"?(Required)(Hint: A Land Trust allows you to transfer ownership (title to real property) to a legal entity that holds the land for the benefit of a beneficiary) Yes No Please list the beneficiaries of the Trust:(Required)Full NameDOBRelationship to Trust OwnerPrimary or Secondary Beneficiary? Add RemoveIs the property deeded to the Trust?(Required) Yes No If so, confirm if the Owner of the Property be listed as the Trust, or the Trust's Owner?(Required) Owner is the Trust Owner is the Trust's Owner Property InformationProperty Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Type of Property:(Required) Single-Family Multi-Family Condo Townhouse # of Units:(Required)Please enter a number from 0 to 999.Year Built:(Required)Construction Type:(Required) Frame Brick Stucco Other Square Footage:(Required)Number of Stories:(Required)Please enter a number from 0 to 999.Entity name/ type of business that owns property:(Required)Is your property in a gated community?(Required) Yes No Name of Community:(Required)Date you purchased this property?(Required)Purchase Price:(Required)Please enter a number from 0 to 9999999.Is this house on a concrete slab or does it have a raised foundation (crawlspace)?(Required)Is the house on a flat ground or is there a slight to moderate slope?(Required)Number of bedrooms:(Required)Please enter a number from 0 to 99.Number of bathrooms:(Required)Please enter a number from 0 to 99.Has the house been earthquake (EQ) retrofitted?(Required) Yes No Does the property have an EQ gas shut off valve?(Required) Yes No Do you have a garage or carport?(Required) Yes No If yes, how many cars capacity?(Required)Is it an attached, detached or built-in garage or carport?(Required)What type of roof do you have?(Required)How old is your roof (in years)?(Required)When was the roof last repaired, upgraded or replaced?(Required)What materials are your outside walls made of?(Required)What’s the percentage of the total interior flooring?(Required)Are the interior walls/ceilings drywall only, or are there walls with tiles, mirrors, wall paper?(Required)Do the ceilings and interior in general have any special features?(Required)What kind of wiring do you have in the home?(Required) Copper Aluminum Knob & Tube If Aluminum/Knob & Tube, do you plan on replacing the wiring in an upcoming renovation?(Required) Yes No What do your electrical systems consist of?(Required)Hint: Fuses are more common in older homes Circuit breakers Fuses Please describe your primary heating system:(Required)Furnace, radiant floor heating, etc.What primary door locks do entrances/exits have?(Required)Hint: A spring lock is a mechanism that retracts the lock with the turn of the knob, usually used for interior/bedroom doors. A deadbolt lock is a lock that can only be applied inside manually or outside with a key, that extends a bolt into the door frame. Deadbolt locks Spring locks Both Does the home have an elevator?(Required) Yes No How many sliding glass doors does your house have?(Required)Please enter a number from 0 to 99.How many French doors does your house have?(Required)Please enter a number from 0 to 99.How many fireplaces?(Required)Please enter a number from 0 to 99.How many chimneys?(Required)Please enter a number from 0 to 99.Do you have any skylights?(Required) Yes No If yes, how big are they and how many are there?(Required)Do you have any solar panels?(Required) Yes No Do you have central air and heat?(Required) Yes No Are your smoke detectors battery operated or are they connected via electrical wiring?(Required) Battery Electrical Other Are smoke detectors local or central?(Required)Local alarms flash and sound, alerting individuals in that specific location. A central alarm will do the above, and notify a central station that can then dispatch authorities. Local Central No Alarm Are burglar/security alarms local or central?(Required)Local alarms flash and sound, alerting individuals in that specific location. A central alarm will do the above, and notify a central station that can then dispatch authorities. Local Central No Alarm Do you have a camera system installed?(Required) Yes No Do any of the windows have bars on them?(Required) Yes No Does your home have a sprinkler system installed?(Required) Yes No Have any of the following been updated or upgraded since your home was originally built? 1. Wiring?(Required) Yes No Is the wiring...?(Required) Full Partial Last renovation (year)?(Required)Please enter a number from 1800 to 2026.2. Plumbing?(Required) Yes No Is the plumbing...?(Required) Full Partial Last renovation (year)?(Required)Please enter a number from 1800 to 2026.3. Heating / AC?(Required) Yes No Is the Heating/AC...?(Required) Full Partial Last renovation (year)?(Required)Please enter a number from 1800 to 2026.Do you have any custom work done on the house?(Required) Yes No If yes, please describe:(Required)Do you have a Jacuzzi or a pool?(Required) Yes No Is your pool fenced in?(Required) Yes No Do you have a trampoline in your back yard?(Required) Yes No Do you own any exotic animals?(Required) Yes No How many?(Required)Please enter a number from 0 to 99.Please list species:(Required) Add RemoveDo you own any dogs?(Required) Yes No How many?(Required)Please enter a number from 0 to 99.Please list breeds:(Required)If you don’t have any dogs, do you plan on getting one in the future?(Required) Yes No Breed:(Required)Renovation/Construction DetailsIs the home currently under construction or renovation?(Required) Yes No Is the property locked and secured during non-working hours?(Required) Yes No Is there lighting on the property?(Required)(Outdoor lighting not dependent on property power) Yes No Is there a 24 hour guard on premises?(Required) Yes No Is this a gated/guarded community?(Required)(You need a gate opener/key to get into community) Yes No Any other security measures not mentioned above?Are you using a licensed contractor for the renovations/construction?(Required)(You hired a contractor to oversee and manage the renovation) Yes No (a) Name of Contractor:(Required)(b) License Number:(Required)(c) Does the Contractor have General Liability coverage in place?(Required) Yes No (d) If so, what is their Limit of General Liability?(Required)Are You acting as the contractor for the renovations/construction?(Required)(You are overseeing the project instead of hiring a contractor to manage it) Yes No (a) If you are acting as a contractor, please describe your years of experience, job types worked on, etc.(Required)(b) Does You have General Liability coverage in place?(Required) Yes No (c) If so, what is their Limit of General Liability?(Required)Are you using subcontractors?(Required)(Specialist for a job like plumbing, electrical work, etc.) Yes No If subcontractors are used, are they licensed?(Required) Yes No Do you obtain evidence of insurance from subcontractors?(Required) Yes No If any contractor/subcontractors are unlicensed, please describe their years of experience, job types worked on, etc.(Required)Renovation/Construction Start Date:(Required) MM slash DD slash YYYY Renovation/Construction End Date:(Required) MM slash DD slash YYYY Current percentage of completion:(Required)Please enter a number from 0 to 99.Describe in full detail all of the current construction/renovations:(Required)Coverage InfomationHave you had any claims in the past three years?(Required) Yes No 1. Type of loss?(Required)2. Approximate amount of damages paid out:(Required)3. Date of loss:(Required) MM slash DD slash YYYY What are your current limits of liability?(Required)Please enter a number from 0 to 9999999.What is your current deductible?(Required)Please enter a number from 0 to 9999.What is your home's current replacement value? (Coverage A)(Required)Please enter a number from 0 to 9999999.Who is your current insurance carrier?(Required)What is your current insurance expiration date?(Required) MM slash DD slash YYYY What is your current premium?(Required)Do you have a mortgagee?(Required) Yes No Do you have more than one mortgagee?(Required) Yes No If yes, please provide the following info: Bank or Lender Name:(Required)Phone Number(Required)Loan Number:(Required)Is this policy going to be paid for in full through escrow?(Required) Yes No Contact info:(Required)Do you currently own any other properties?(Required) Yes No If yes please describe below:(Required)Additional InformationUse the space below to provide any other relevant information or special considerations that may affect your insurance policy. Δ
