If you are human, leave this field blank.Agent InformationAgency NumberAgency Name *Agency Contact *Agency Email *Contact Phone *Insured InformationName of Insured *Insured Type *AssociationCorporationIndividualJoint VentureLLCLLPPartnershipProprietorshipTrustOtherDate of Birth *Occupation *Mailing AddressStreet Number *Street Address *City *State *FLTXZip *Risk InformationProposed Effective Date *Target Premium $ *Risk LocationStreet Number *Street Address *City *State *Zip *County *Underwriting InformationOccupancyLapse in CoverageYesNoIf Yes, # of daysBuilders RiskNoCOCRenovationOccupancy Type *Builders RiskBuilders Risk with RenovationAnnual RentalPrimaryShort Term Rental (daily, weekly, monthly, etc..)SecondarySecondary RentalVacantConstruction Type *FrameLogMasonryMasonry VeneerMetalSuperiorRoof Type *FlatGableHipNo of Weeks Rented *Minimum Rental Length *Protection Class *Year Built *Square Ft. *No of Stories *Roof Material *ShingleTileMetalSlateFlat – tar/gravelFlat – membraneRoof Shape *HipGableFlatOtherProperty for Sale?YesNoYear of updates on 25 or olderRoof Update202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989Roof Status CompletePartialElectrical Update202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989Electrical StatusCompletePartialHVAC Update202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989HVAC StatusCompletePartialPlumbing Updates202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989Plumbing StatusCompletePartialLoss History-Date/Type/AmountProtective DevicesCentral Burglar AlarmGated CommunityCentral Fire AlarmInterior SprinklersWind Mitigation FeaturesHurricane ShuttersPre-Cut PlywoodWind Resistive GlassClipsSingle Wraps or BetterOptional EndorsementsID Fraud125% Extended Replacement Cost DwellingEarthquake with 5% deductibleMechanical BreakdownPersonal InjuryReplacement Cost ContentsWater Back Up Limit$5,000$10,000$25,000$50,000Mold Limit$5,000$10,000$25,000$50,000Loss Assessment LimitAdditional OptionsCoverage LimitsCov. A - DwellingCov. B - Other StructureCov. C - Personal PropertyCov. D - Loss of UseCov. E - Personal LiabilityCov. F - Medical PayAOP Deductible$1,000$2,500$5,000$10,000$25,000$50,000Wind/Hail Deductible1%2%3%5%10%ExcludeNamed StormAdditional Options or InformationAnimals on premises?Type of BreedSwimming Pool or Trampoline?If yes, is yard fencedYesNoUpload file here to submit with quote requestBuilder’s Risk Quotes ONLYName of Contractor/BuilderBuilder's Risk/RenoBuilder's RiskRenovationGround Up ConstructionProject StartEst. CompletionPurchase Price $Est. Completion Value $% of Project Comp0%5%15%25%50%75%90%100%Construction FinancingLighting on PropertyYesNoGated CommunityYesNoTheft of Building MaterialsYesNoLiabilityYesNoCentral Station AlarmYesNoLicensed Contractor/BuilderYesNoFlood OptionsUnderlying & XS FloodXS OnlyDwelling in XS of $250,000Contents in XS of $100,000ZonePost/Pre FirmPost-FirmPre-FirmIf Post-Firm A or V, Elevation Difference Between Risk and BFE:Submit
