Home Insurance Quote

Applicant Name*

First NameLast Name

Applicant DOB?*

Date

Is there a co-applicant?*

YesNo

Co-Applicant Name*

First NameLast Name

Co-Applicant DOB?*

Date

Will the property be owned by a corporation?*

YesNo

What is the corporation's name?*

Please provide corporation name as shown on property appraiser

Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

example@example.com or N/A if no email

What will be the purpose of this property?*

HO - Residence of InsuredDP - Rental PropertyOther

What is the construction of the property?

Masonry - Block or ConcreteFrame - Wood or AluminumOther

How many months a year do you reside at this property?*

9-12 Months5-8 Months0-4 Months

Do you require at least an annual lease?*

YesNo

Do you allow any form of short term rental?*

YesNo

What is the home type?*

How is Mobile Home Situated?*

Non-Owned Private PropertyOwned Private PropertyMobile Home ParkSenior Mobile Home Park

Are you responsible for the exterior of the property and the roof?*

YesNo

Make of the Home?*

Ex. Fleetwood or Palm Harbor if unsure notate.

Square Footage of Mobile Home*

Customer can also provide length and width

Serial Number of the Home?

Typically located in kitchen cabinet or master closet if unsure notate.

Age of the Mobile Home?*

Structures of the Mobile Home?*

Ex, Attached Sunroom 400 square foot worth 5,000 or unattached shed that is 350 square feet worth 3000. If no other structures are provided put N/A in the field.

Do you have a wind mitigation form?*

YesNo

Alarms in the home?*

YesNo

Specify Further?*

Please note monitored alarms can be ONLY burglary, ONLY fire, or BOTH. Local can simply be smoke detectors or un-monitored alarm.

If Home is new construction, who is the builder?

Only ask this question if home is currently under construction or was very recently finished being built.

Community Access Discount?

Single EntryGated with GuardsKeycode Entry Gated

Is there any existing damage or debris on the property?*

YesNo

Has coverage on this property been cancelled, rejected, or non-renewed in the last three years?*

YesNo

Will the property be occupied within 30 days of effective date?*

YesNo

Do you own any animals?*

YesNo

What kind of animal?*

Include species and breed. (ex. a dog; chihuahua)

Pool on the property?*

YesNo

Pool Area Screened? OR Yard Entirely Fenced?*

YesNo

Are there currently any type of renovations or construction occurring on the property?*

YesNo

Are there currently any type of renovations or construction occurring on the property?*

YesNo

Was the home purchased through short-sale or foreclosure?*

YesNo

Does your home have any burglar bars installed?*

YesNo

Do the bars have quick release mechanisms?*

YesNo

Has this property or any properties you've owned sustained in damage that resulted in a claim in the past 5 years?*

YesNo

Please detail all losses with locations, dates, amounts, type of damage, and status of claim.*

Ex, Water Damage 5/10/2015 $30,000 Paid Out Claim is Closed.

Year Roof was Installed/updated?*

Roof Type*

Please Describe*

Year HVAC was installed/updated?*

Year plumbing was installed/updated?*

Are you aware of the presence of Polyethylene in your home?*

YesNo

Year electrical was installed/updated?*

To your knowledge is your electrical panel made by Federal Pacific or Sylvania?*

YesNo

To your knowledge does your home contain any aluminum, cloth, or knob and tube wiring?*

YesNo

Please retain this completed on the applicants file. If the applicant purchases a policy, this document is required to be sent for signature alongside their applicant and should be saved on the file after signature is obtained.

Customer Signature

Karla Salmon Insurance

1890 W County Road 419 Ste 2030

Oviedo, FL 32765

407-478-8808

www.karlasalmoninsurance.com

Property Insurance Quote Sheet

Basic Information

Determining Policy Form

Discount Questions!

Loss History