Home Intake Form Name(Required) First Last Gender(Required)Please SelectMaleFemaleNon-BinaryDate Of Birth(Required) Month Day Year Phone(Required)Email(Required) Marital Status(Required) Single Married Spouse Name First Last GenderPlease SelectMaleFemaleNon-BinaryDate of Birth Month Day Year Is there a separate mailing address?(Required) Yes No Mailing Address(Required) Street Address 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 Physical Address(Required) Street Address 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 Have You Lived At This Address Less Than 3 Years?(Required) Yes No If Yes, Please Provide Previous 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 Policy Effective Date(Required) MM slash DD slash YYYY Property Purchase Date(Required) MM slash DD slash YYYY Any Mortgage?(Required) Yes No Is this your primary residence?(Required) Yes No If no, is this a secondary home or rental property (tenant occupied)(Required)Please SelectSecondary HomeRental Property (tenant occupied)Is the property held in your Trust?(Required) Yes No If yes, please provide Trust Name and Date Established(Required) Is the property under construction, vacant, unoccupied or for sale?(Required) Yes No If yes, please explain(Required) Are there any dogs in the household?(Required) Yes No If yes, how many dogs are in the household?(Required) If Yes, do any of the dogs have a biting history?(Required) Yes No If yes, are any of the dogs one of the following; Akitas, Cane Corsos, Chows, Pit Bulls, Presa Canario (canary dog), Rottweilers, Staffordshire Bull Terriers, Wolf Hybrids, or a mix of any of these breeds?(Required) Yes No Are there any livestock/Horses on premise?(Required) Yes No If yes, what type and how many?(Required) Are there any exotic animals/reptiles on premise?(Required) Yes No If yes, what type and how many?(Required) Is any daycare business conducted on the premises?(Required) Yes No If yes, please explain(Required) Any skateboard ramps, bicycle jumps, or trampolines on the premises?(Required) Yes No If yes, please explain(Required) Any swimming pools, jacuzzis, hot tubs or spas on the premises?(Required) Yes No Is there any diving board, springboard, or slide?(Required) Yes No Does the insured engage in any type of residential farming?(Required) Yes No If yes, please explain(Required) Is there a Homeowners Association?(Required) Yes No Do you own any luxury or high value items with a purchase price over $1,000 each or $5,000 collectively?(Required) Yes No If yes, please explain(Required) Any detached structures? (Guest House, Pool House, Outdoor Kitchen, etc.)(Required) Yes No If yes, please explain(Required) Are there solar panels?(Required) Yes No If yes, Leased or Owned(Required) Leased Owned How Many Panels?(Required)Please Select1-1415-3030+Any prior claims in the last 5 years?(Required) Yes No If Yes, please provide date, description of loss, and amount paid (roughly)(Required) Is there Fire Extinguishers?(Required) Yes No Is there a Fire Sprinkler System?(Required) Yes No Do you live in a gated community?(Required) Yes No If yes, please select an option(Required) Gated Gated and Guarded/Live Patrol Do you have a central reporting Burglar and/or Fire Alarm?(Required) Burglar Fire Both None Dwelling Usage(Required)Please SelectPrimarySecondary (vacation)FarmVacantCourse of ConstructionDwelling Type(Required)Please SelectSingle Family2 Plex3 Plex4 PlexYear Built(Required) Square Footage(Required) Number of Stories(Required)Please Select11.522.533.54Construction Type(Required)Please SelectStucco On Frame< 67% Brick Veneer> 67% Brick VeneerSiding, WoodSiding, VinylSiding, SteelLogs, SolidStone On FrameGarage(Required)Please SelectAttached- 1 CarAttached- 2 CarAttached- 3 CarAttached- 4 CarDetachedNo GarageFoundation Type(Required)Please SelectSlabCrawl Space (raised)PiersBasementRoof TypePlease SelectCompositeClay TileConcrete TileFlat Tar GravelWood ShakeCorrugated Steel MetalType of PlumbingPlease SelectCopperPEXGalvanizedPVCElectrical TypePlease SelectCircuit Breaker/ Copper Wiring (Safest Most Common)Circuit Breaker/Aluminum WiringFuse Box/Copper WiringFuse Box/Aluminum Wiring*Utility Updates: If you don't know, please put unknown and follow up with Realtor, Current Owner, or Property Manager for information.Year Roofing Replaced Year Plumbing Updated Year Electrical Updated Year HVAC Updated How did you hear about us? UPLOAD CURRENT POLICY DECLARATION PAGES HERE*Max. file size: 98 MB.*If the information provided through this Form are incomplete or incorrect, your final quote may change.hCaptcha(Required)
