Personal : Homeowners

Name Spouse Name (if applicable)

Mailing Address
Street/PO Box
City
Zip/Postal Code
Home Telephone Work or Cellular Telephone
Email Address
Years at current residence Effective Date


Applicant Information

Location Address (if different from mailing address)
Street Address
City
Zip/Postal Code


Applicants Occupation
Applicants Date of Birth
Employers Name
Employers Address
City
Zip/Postal Code

Spouse's Occupation
Spouse's Date of Birth
Employers Name
Employers Address
City
Zip/Postal Code


Coverages/Limits of Liability
Dwelling Limit $
Liability Limit


Rating/Underwriting


Year Built Square Feet
Structure Type
Usage Type
Housekeeping Condition
County where home is located
Number of Amps (Electrical System)
Dwelling Location
Occupancy

Circuit Breakers
Fuses
Knob and Tube or Aluminum Wiring
Plumbing Leaks
Foundation
Deadbolts
Fire Extinguisher
Visible to Neighbors
Occupied Daily
Swimming Pool
If "Yes" select features

Number of Weeks Rented
Roof Material Condition of Roof


Prior Coverage
Prior Carrier
Expiration Date


General Information
Any farming or other business conducted on premises? (including day/child care)
If "yes", please explain
Any residence employees?
If "yes", please list number of full and part-time employees
Any flooding, brush, forest fire hazard, landslide, etc?
If "yes", please explain
Any other residence owned, occupied or rented?
If "yes", please explain
Any other insurance with this company?
If "yes", please list policy numbers
Has insurance been transferred within agency?
If "yes", please explain
Any coverage declined, cancelled or non-renewed during the last 3 years? (not applicable in MO)
If "yes", please explain
Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during
the past five years?
If "yes", please explain
Are there any animals or exotic pets kept on premises?
If "yes", please note breed and bite history
Is property situated on more than five acres?
If "yes", please describe land use
Does applicant own an recreational vehicles (snow mobiles, dune buggys, mini bikes,
ATVs, etc)?
If "yes", please list year, type, make, model
Is building retrofitted for earthquake?
If "yes", please explain
During the last five(5) years(ten(10) years in Rhode Island), has any applicant
been indicted for or convicted of any degree of the crime of fraud, bribery, arson
or any other arson-related crime in connection with this or any other property?
(in RI, failure to disclose the existence of an arson conviction is a misdemeanor
punishable by a sentence of up to one(1) year of imprisonment.)
If "yes", please explain

Following three(3) questions are for Renters and Condos only:
Is there a manager on the premises?
Is there a security attendant?
Is the building entrance locked?
Any uncorrected fire or building code violations?
If "yes", please explain
Is building undergoing renovation or reconstruction?
If "yes", please give estimated completion date and dollar value
Is house for sale?
If "yes", please explain
Is property within 300 feet of a commercial or non-residential property?
If "yes", please explain
Is there a trampoline on the premises?
If "yes", please explain
Was the structure originally built for other than a private residence and then converted?
If "yes", please explain
Any lead paint hazard?
If "yes", please explain
If a fuel oil tank is on premises, has other insurance been obtained for
the tank?
If "yes", please give First Party and limit, and Third Party and limit
If building is under construction, is the applicant the general contractor?
If "yes", please explain


Distance to tidal water?


Loss History
Any losses, whether or not paid by insurance, during the last     years, at this or at any
other location?
Description of Loss
Date
Amount


Lienholder Information
Name
Street/PO Box
City
Zip/Postal Code
Loan Number
Disclaimer: The request will not become effective until after you have been contacted by one of our agents. Check this box to confirm.
Request A Quote Request A Certificate Report A Claim

Helpful Information Helpful Links Privacy Policy Terms of Use Contact Us

This website is not intended as a solicitation to sell insurance in those states where SFI Group, Inc is not properly licensed to sell insurance.

Licensed to operate in:
VA,NC,SC,GA,FL,AL,MS,LA, DE,
and TX

Copyright ©2008 SFI Group, Inc. :: Helpful Information | Helpful Links | Contact | Site Map | Privacy Policy | Terms of Use Wilmington, NC web design by Inspire