FLORIDA
HOME OWNERS INSURANCE
APPLICANT'S INFORMATION:
First Name:
Last Name:
Date of Birth:
Street:
Street (2):
City:
State:
AK
AL
AR
AZ
CA
CO
DC
CT
DE
FL
GA
HI
IA
ID
IN
IL
KS
KY
LA
MA
MD
ME
MI
MN
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
Phone Number:
Email Address:
Do you have current insurance?:
No
Yes
Is this a new home purchase?
No
Yes
Residence type:
Primary
Secondary
Rental
FLORIDA
HOME OWNERS INSURANCE
PROPERTY/COVERAGE INFORMATION:
Number of stories:
1 Story
2 Story
Year of Construction?
Heated Square Footage?
Number of Bed/Bath:
1/1
2/1
2/2
3/1
3/2
3/3
4/2
4/3
Roof type:
Shingle
Tile
Metal
Year of installation?
Home Design?
Single Family Home
Condominium
Townhouse
Mobile Home
Duplex Owner
Triplex Owner
Quad Owner
Construction?
Frame
Stucco over Frame
Masonry
Brick
Brick Veneer
Foundation?
Concrete Slab
Elevated on Blocks/Piers and Enclosed
Elevated on Blocks/Piers, Not Enclosed
Crawl Space
Gara ge?
None
1 Car Attached
2 Car Attached
1 Car Detached
2 Car Detached
1 Car Carport
2 Car Carport
3+ Car Attached
3+ Car Attached
Pool?
None
Inground
Above Ground
Fenced?
No
Yes
N/A
Diving Board?
No
Yes
N/A
Screened?
No
Yes
N/A
Is there a jacuzzi/hot tub?
No
Yes
Do you have a fireplace?
No
Yes
Do you have a trampoline?
No
Yes
Safety/Security Features?
None
Hurricane Shutters
Burglar Alarm
Smoke Alarm
More Safety/Security Features?
Hurricane Shutters
Burglar Alarm
Smoke Alarm
Do you have a dog?
No
Yes
List Dog
Breeds:
Any optional coverages or scheduled
items?