Homeowners Insurance Application

The complete homeowners application, in seven sections. Fill in what you know — you don't have to finish every field to send it, and we'll follow up on anything missing.

josh@contractorschoiceagency.com

Applicant and Policy Information

Please provide legal names exactly as they should appear on the policy.

APPLICANT INFORMATION

Primary Applicant - Full Legal Name*

Date of Birth

Marital Status

Co-Applicant - Full Legal Name

Date of Birth

Marital Status

Primary Phone*

Alternate Phone

Email Address*

Current Mailing Address

City

State

ZIP

EMPLOYMENT AND IDENTITY

Applicant Occupation

Employer

Years Employed

Co-Applicant Occupation

Employer

Years Employed

Applicant Driver License Number

State

Co-Applicant Driver License Number

State

POLICY REQUEST

Requested Effective Date

Current Carrier

Current Policy Number

Current Annual Premium

Years With Current Carrier

Expiration Date

Reason for Shopping

CONTACT AND DOCUMENT PREFERENCES

Additional named insureds or household contacts

Email documentsMail documentsText notificationsElectronic signature

Dwelling Construction and Building Details

Use best available information; inspection reports may be attached.

CORE DWELLING CHARACTERISTICS

Year Built

Total Living Area Sq. Ft.

Number of Stories

Number of Units

Construction Type

Exterior Wall Material

Foundation Type

Roof Shape

Roof Material

Roof Year / Age

Roof Condition

Roof Replacement Cost

Roof Permit Date

INTERIOR AND ATTACHED STRUCTURES

Bedrooms

Bathrooms

Garage Spaces

Garage Type

Basement Sq. Ft.

Finished Basement Sq. Ft.

Porch / Deck Sq. Ft.

Carport Sq. Ft.

Other Attached Area

Flooring Type(s)

Kitchen Quality

Bathroom Quality

Custom Features

DETACHED STRUCTURES

Detached Garage / Shop Sq. Ft.

Guest House Sq. Ft.

Other Structure Type

Fence Type / Length

Solar Panels - Owned or Leased

Other Structure Value

Loss History, Mortgagee, Remarks, and Authorization

Report all property and liability losses for all locations during the past five years.

LOSS HISTORY

Loss 1

Date

Location

Type / Cause

Amount Paid

Status

Claim Number

Loss 2

Date

Location

Type / Cause

Amount Paid

Status

Claim Number

Loss 3

Date

Location

Type / Cause

Amount Paid

Status

Claim Number

Loss 4

Date

Location

Type / Cause

Amount Paid

Status

Claim Number

MORTGAGEE / ADDITIONAL INTEREST

Mortgage Company / Lender

Loan Number

Mortgagee Mailing Address

City

State

ZIP

Second Mortgage / HELOC Lender

Loan Number

PRODUCER REMARKS AND ATTACHMENTS

Additional underwriting remarks

Prior declarations attachedLoss runs attachedInspection attachedPhotos attached

APPLICANT AUTHORIZATION

Applicant Signature

Date

Producer / Agency

Co-Applicant Signature

Date

Producer Phone

I certify that the information in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may affect eligibility, coverage, or claims. I authorize the insurer and its representatives to obtain insurance scores, loss history, inspection data, and other underwriting information as permitted by law. This application does not bind coverage.

This application does not bind coverage. Your information is secure and never sold.

Homeowners Insurance Application

Applicant and Policy Information

Property, Occupancy, and Ownership

Dwelling Construction and Building Details

Utilities, Systems, Protection, and Updates

Premises Liability and Underwriting Exposures

Coverage Selection and Valuation

Loss History, Mortgagee, Remarks, and Authorization