Owners First Name * Owners Last Name Primary Phone Number * Secondary Phone Number Email Address Co- Owners First Name Co- Owners Last Name Property Address (Number & Street) Property City, State, & Zip Code Current Homeowners Insurance Please Select Currently insured Insured within the last 30 days Insured within the last 90 days No coverage within the last 90 days New home, moving in Amount of Dwelling Coverage on Current Policy Current Insurance Expiration Date Type Dwelling Please Select Single Family Home Condo Townhome, or Villa Duplex Other Type of Residence Please Select Primary Secondary Seasonal Construction Please Select Concrete Block/Masonry Wood Frame Mostly Brick Brick Veneer Masonry Veneer Other Stories Please Select 1 2 Other Year Built Square Footage under A/C Type Roof Please Select Shingle Concrete Block Rolled Roof Other Roof redone? Please Select Not sure Roof has never been redone Roof redone before 2002 Roof redone 2002 or later Shape of Roof Please select Not Sure Flat Gable Hip Mansard Other Hurricane Shutters On All Openings? Select One No Yes - Permanently Attached to home Yes - Not permanently attached Yes - But not on all openings Not Sure Number of Bedrooms/Bathrooms Please Select 1/1 2/1 2/2 3/1 3/2 3/3 4/2 4/3 4/4 Other Garages & Carports Please Select None 1 Car attached garage 2 car attached garage 3 car attached garage 4 car attached garage 1 car detached garage 2 car detached garage 3 car detached garage 4 car detached garage 1 car attached carport 2 car attached carport Other Swimming Pool Please Select No Swimming Pool Attached small concrete pool Attached medium concrete pool Attached large concrete pool Detached small concrete pool Detached medium concrete pool Detached large concrete pool Other Pool Enclosure Please Select No pool enclosure Fence less than 4 foot high or unlockable 4 foot high, lockable fence Screened Enclosure/Cage Other Porches & Patios Please Select Small open Medium open Large open Small Screened Medium Screened Large Screened Small Enclosed Medium Enclosed Large Enclosed Other Additional Porches & Patios Please Select None Open small Open medium Open large Screened small Screened medium Screened large Enclosed small Enclosed medium Enclosed large Other Detached Structures Please Select None Fence around yard Shed Fence & Shed Other (please enter below) Fireplace Please Select No Yes In a Flood Zone Please Select Yes No Not Sure Monitored Fire & Burglar Alarm Please Select No Yes Fire Station within 5 miles Please Select Yes No Not sure Fire Hydrant within 800 feet Please Select Yes No Not sure Trampoline on Premesis Please Select No Yes Were you satisfied with any hurricane claims you may have filed since 2004? Please Select Did not file any claims Did not, but should have filed claim Satisfied with my claim Not satisfied with my claim Other Additional Comments