Please complete as much information as possible. If you have any questions about this form, please contact us.

How did you find us?
Friend Yellow Pages Online Search Engine Real Estate or Mortgage Broker

Home Closing Date

Policy Renewal Date

Current Home Insurance Company

Name

D.O.B

Is your credit
Good Fair Not Good

Property Address

City

State

Zip

Is your property a?
Condo Home Manufactured Home

Are you in a development?

No Yes

If Yes, name of development or community:

Is it gated?
No Yes

Home Phone

Office Phone

Cell Phone

Fax

E-Mail Address

Preferred Contact Method
Home Phone Email Cell Phone Office Phone Fax

Mailing Address


City, State, Zip

Do you want Flood Insurance?
No Yes

Bankruptcy, Foreclosure, Repossession, Lien, or Judgments in the last 5 years?
No Yes

Year Built

Roof Type

Roof Age

Amount of Coverage for Home

Construction
Cement Block Frame Manufactured

Foundation
Closed Open Skirting

Number of Bedrooms

Number of Bathrooms

Square feet under air

Garage?
No Yes

Number of Cars

Number of Floors

Any Unattached Structures?
No Yes

If Yes Please Describe

Any Attached Structures?
No Yes
If Yes
Carport No Yes Length Width
Florida Room No Yes   Length Width
Screen Room No Yes   Length Width
Wooden Deck No Yes Length Width
Shed No Yes Length Width
Aluminum Awning No Yes Number
Other Describe:

If over 15 years old, has the electric, plumbing, air conditioning, heat, or roof been updated?

Do you have a Golf Cart?
No Yes

Hurricane Shutters?
No Yes

Patio or Deck?
No Yes

Pool?
No Yes Screened Fenced

Central Alarm Fire Burglary

Do you own a Boat?
No Yes

Make

Horsepower

Length

Drive Type
Outboard Inboard Sail

Business Use
No Yes

Part Time Rental
No Yes

Occupancy
Owner Tenant

Number of Occupants

Do you have a Dog(s)?
No Yes Number of

Breed

What Deductible?
$500 $1000 $2500

Additional Coverage Amounts
Jewelry
Guns    
Fur       
Art       

Residence Type
Primary Secondary Seasonal Tenant

Claim experience for the last five years


Do you have a personal Umbrella?
No Yes

Have you ever discussed this with you Agent?
No Yes

Submitting an insurance quotation request to J Meyers Insurance Group does not constitute a binding confirmation of new or altered insurance coverage.
Verbal or written confirmation must be obtained from J Meyers Insurance Group to confirm binding or altering coverage.