Please enable JavaScript in your browser to complete this form.Account Manager *HollyJinetteVictoriaNatalieInsured Name *FirstLastConfirm Nexsure Information *Confirm best phone # and/or email address for insured is primary in NexsureConfirm insured(s) date of birth is correct in NexsureCurrent Policy # *What line of business is the policy being converted to? *HO3HO4DP3HO6Usage *PrimarySecondaryTenantCoverage Effective Date *How many months of the year will they live in this property? *Mailing Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAge of Home *0-10 Years10-30 Years30-50 years50+ yearsHas or will a 4-point inspection be completed on the property? *The client/prospect will send the 4-point inspection4-point inspection is attached in NexsureNo 4-point inspection will be completedWhen will the 4-point inspection be sent? *Roof Age *Has or will a wind mitigation inspection be completed? *The client/prospect will send the wind mitigation inspectionWind mitigation inspection is attached in NexsureNo wind mitigation will be completedHas the condo association completed a wind mitigation inspection? *The client/prospect will send the wind mitigation inspectionWind mitigation inspection is attached in NexsureNo wind mitigation will be completedDoesn't KnowWhen will the wind mitigation inspection be sent? *Year Water Heater Replaced/Water Heater Age *Year AC/Heating Replaced *Year Electrical Updated *Type of Plumbing *PVCCast IronCopperGalvanizedPolybutyleneFoundation Type *SlabOpen FoundationCrawl Space (25%)Crawl Space (50%)Crawl Space (100%)Piers (Elevated)BasementSolar Panels *YesNoStructure Type *Single FamilyCondoApartmentTownhouseSquare Footage *Stories in the Building *Floor Unit is On *# of Units in Building *How much personal property insurance do they need? *Is the property being rented at any time during the year? *YesNoHow frequent are their rentals and/or tenant leases? *How many rental properties do they currently own? *Pets or Animals *YesNoType of pets/animals *Bite or Attack History *YesNoDescribe Bite or Attack History *Are there any special features or upgrades to the home that we should know about when quoting? *YesNoDescription of Special Home Upgrades *Flood InsuranceIs flood insurance required? *NoYes - Needs QuoteYes - Already Has Flood PolicyIs an elevation certificate being completed? *The client/prospect will send the elevation certificateElevation certificate is attached in NexsureNoWhen will elevation certificate be sent? *Underwriting InformationAny insurance claims on any property they have ever owned? *YesNoDescription of Claims *Has property insurance been cancelled, declined, or non-renewed in the last 5 years? *YesNoDescription of Property Insurance Cancelled, Declined, or Non-Renewed *Is it okay to run insurance score? *YesNoAdditional NotesDocuments Click or drag files to this area to upload. You can upload up to 10 files. Information CollectorSubmit
