Habitational Quote RequestAll FormsAutomobile Quote RequestBoat Quote Request (PDF)Employee Census (PDF)Employment Applications (PDF)Fact Find FormCommercial Risk Quote RequestHabitational Quote RequestHealth Insurance Quote Request (PDF)Homeowners Quote Request (PDF)Mobile Home Insurance Quote Request (PDF)Personal Umbrella Request (PDF)1 Names and Contacts2 Requested Coverages3 Sizes and Usage4 Property Descriptions, Conditions, Improvements5 Security & Safety6 Amenitites7 Recreational8 Loss History SummaryNames & Contacts(11 Questions)Client Contact Name* First Last Client Contact Email* Client Contact PhoneClient Contact FaxProperty NameProperty Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Property County or Parish Save and Continue LaterRequested Coverages(4 Questions)Current Insurance CarrierCoverages to Quote Property General Liability Excess Liability Boiler / Machinery Workers Compensation Flood UmbrellaCheck all that applyExcess Liability Limit*Limits: BuildingLimits: ContentsGross Potential Annual Income Save and Continue LaterSizes and Usage(16 Questions)Year Built (YYYY)Gross Square Feet (all insured buildings)Number of UnitsNumber of BuildingsNumber of Stories (including basements)Maximum Distance Between BuildingsMinimum Distance Between BuildingsParking SpacesRetail / Office Exposure?YesNoRetail / Office Square FootageType of Occupancy% of Occupancy% of Subsidized Units% of Student Housing% of Senior Housing% of Assisted Living Save and Continue LaterProperty Descriptions, Conditions, Improvements(15 Questions)Building DescriptionExterior ConstructionExterior Construction (more than 50%)FrameBrickBrick VeneerStuccoMasonryNon-combHardi-PlankFire ResistiveOtherOther Exterior ConstructionRoof TypeCompositionBuilt-UpTileWood ShakeMetalOtherOther RoofWiring TypeCopperAluminum Pig-TailedAluminumAluminum Co/AlrCircuit Protection Circuit Breakers FusesLast Year Improvements Were Made to (YYYY):RoofWiringHeatingPlumbingOtherDescribe Other ImprovementsIs property currently under renovation?*YesNoDescribe Current Renovation Detailsis Graffiti Present?YesNoCondition of Parking Lots, Sidewalks, Outdoor Public Areas (pot holes, unlevel areas or hazards) Save and Continue LaterSafety & Security(11 Questions)Fire extinguishers in kitchen of each unit?YesNoIf No, is at least one (5lb) on same floor located within 75' of each unit?YesNoSmoke Detectors?YesNoSmoke Detectors located in all sleeping areas and halls/rooms leading to sleeping areas?YesNoFire Sprinkler System?YesNoFire Escapes?YesNoFire Hydrants?YesNoDistance to Fire HydrantsLongest distance from any property area to the nearest fire hydrant.Any interior halls?YesNoDo interior halls have emergency lighting?YesNoDo interior halls have illuminated exit signs?YesNoBars on Windows?YesNoIf yes, is panic release hardware present?YesNoAny Past Assault or Rape Claims?YesNoPlease Describe Save and Continue LaterExterior Amenities(3 Questions)Is there a perimeter fence?YesNoAre there entry gates?YesNoAre there carports?YesNo Save and Continue LaterRecreational Areas / Facilities(5 to 15 Questions)Number of PoolsDo pools have depth markers?YesNoDiving boards or slides?YesNoLife saving equipement in pool area?YesNoSelf-locking gates?YesNoPool rules posted?YesNoPhone accessible?YesNoType of Pool Fence (wrought iron, chain link, brick, etc)Height (ft.) of Pool Fence (0 if none)Club House?YesNoTennis Courts?YesNoFitness Center?YesNoFree Weights?YesNo Save and Continue LaterLoss History SummaryPlease provide a summary of the loss history for the last 5 years for Property and Liability losses. All fields must be completed. If there were no losses for a particular year, place a “0” (zero) in both the paid and reserved blanks. Totals will be automatically calculated for you. Insurance company printouts of loss runs must follow these summaries. Loss run printouts may be submitted by e-mail, fax, or mail.Property LossesYearPolicy YearCarrierPaidReserveTotal Liability LossesYearPolicy YearCarrierPaidReserveTotal CAPTCHA Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.