Agent Information
Agent Name:
Agent Phone:
Agent Email Address:

 

Applicant acknowledges that a CLUE Report CLUE Report Comprehensive Loss Underwriting Exchange: Underwriters use the information in a CLUE report to rate insurance policies. A home's CLUE loss history report provides insurance company names and policy numbers and any claim numbers. The report lists the dates of any claims, the loss types and amounts paid for losses, and it will tell if a claim was denied. may be obtained during the quoting process

 

Applicant's Personal Information
Applicant First Name:	Applicant Last Name:
Applicant Date of Birth:	Applicant Gender: Male Female
Marital Status:	Select... Married Divorced Single Domestic Partner Widowed   Occupation:
Is there a Co-Applicant?:	Select Yes No
Co-Applicant First Name:	Co-Applicant Last Name:
Co-Applicant Date of Birth:	Co-Applicant Gender: Male Female
Marital Status:	Select... Married Divorced Single Domestic Partner Widowed   Occupation:
Property Address:
City:	State:   Zip:
In City Limits?:	Select Yes No
Mailing Address same as Property Address?:	Select Yes No
Mailing Address:
City:	State:   Zip:
Prior Address: (If at Property Address less than 2 years)
City:	State:   Zip:
Phone:
Email Address:
Has property insurance been cancelled, declined or non-renewed in last 5 years?:	Select Yes No         If Yes, please explain below:

Current Homeowners Insurance Information
Do you currently have Homeowner's Insurance?:	Select Yes No
Company Name (not agency):
Policy Information:	Expiration Date	Premium Amount	Amount Insured For
		$	$
Occupancy:	Primary Secondary Tenant Vacant      If rental, how many units owned by the applicant:   1 - 5 6 - 10 11 - 15 16 - 20
Current Deductible:	$     # of Mortgages: 0 1 2 3
# of Claims In Last 3 Years:	Date:	Amount:	Details:
		$
		$
		$
		$
		$
Current Earthquake Coverage?:	Select Yes No   If Yes, through which company?

New Coverage Information
Amount of Coverage Desired:	$
Desired Deductible:	$ 1,000 2,500 5,000
Personal Liability:	$ 100,000 300,000 500,000 1,000,000
Earthquake Coverage:	Select Yes No
Extended Coverage:	$ 125 150

Home Information
Date Applicant Purchased Property:	Year Home Was Built:
Swimming Pool?:	Select Yes No         If Yes, Diving Board: Yes No
Any Pets?:	Select Yes No If Yes, what kind / how many:
Sq. Footage: (excl. garage/basement)	sq. ft.       # of Units: 1 2 3 4
Miles to Responding Fire Dept.:	0-5 Over 5     Feet to Fire Hydrant: 0-500 501-1000 over 1000
Is home more than 20 years old?:	Select Yes No
If home is more than 20 years old, please provide updated information for the following:
Roof:	Year Updated:   Complete Partial None
Electrical:	Year Updated:   Complete Partial None
Heating:	Year Updated:   Complete Partial None
Plumbing:	Year Updated:   Complete Partial None

Structure Information
Type	Construction	Exterior Walls	Roof	Foundation	Garage
1 Story 1 1/2 Story 2 Story Split Level Bi-Level Other (list below)	Frame Veneer Masonry Other (list below)	Stucco on Frame Wood Siding Brick Other (list below)	Asphalt Shingle Wood Shingle Tile or Slate Other	Slab Crawl Space	1 Car 2 Car 3 Car 4 Car None
			Age of roof: yrs.		Attached Detached Basement Built-in Car Port None

Features
Bathrooms	Basement	Deck/Porch/Patio Sq. Ft.	Fireplaces	Kitchen Type
# of Full:   # of Half:	None Finished Unfinished   Sq. Ft.:	Deck:   Porch:   Screened Patio:	None Brick Built-in w/ Wood Chimney # of Chimneys:   # of Hearths:	Economy Semi-Custom Custom Designer Luxury

Additional Features
Heating System	Gas Shutoff Valve	Central Air	Security Alarm	Fire Alarm	Smoke Detector
None Electric Gas Oil Propane Solar Other	Yes No	Yes No	None Monitored Not Monitored	None Monitored Not Monitored	Yes No

Additional Comments

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