Moody Insurance Group Agent You Are Working With: Choose Lenny Aldahondo Jessica Frias Curt Warnke Veronica Skopp Tom Moody Tatiana Rodriguez

Answer the Following Questions To Qualify for Homeowners Coverage

1. Does the applicant own any recreational vehicles (personal watercraft, snow mobiles, dune buggys, mini bikes, ATVs, etc)? Choose Yes No

2. Is there a trampoline on premises? Choose Yes No

3. Does the community have at least 30 homes and patrolling security guards and a six foot fence completely surrounding the neighborhood and guards at all entrances? Choose Yes No

4. Is property owned by a Corporation, Public Association, Limited Liability Corporation or similar entity? Choose Yes No

5. Is property classified as a motor home, house boat, house trailer, trailer home, manufactured home, or mobile home? Choose Yes No

6. Is property eligible for coverage under a commercial policy? Choose Yes No

7. Is property located where farming or ranching activities take place? Choose Yes No

8. Is any insured building heated by a wood burning stove, space heater, or any portable device? Choose Yes No

9. Is there a swimming pool on this property? Choose Yes No
Does pool have a diving board? Choose Yes No
Does pool have a slide? Choose Yes No
Is there a permanent lockable fence surrounding the pool? Choose Yes No Choose Yes No

10. Are there more than 2 mortgagees? Choose Yes No

11. Are there any animals or exotic pets kept on premises? Choose Yes No
Do animals have a history of biting or attacking? Choose Yes No
Have any of the animals been trained as attack or guard dogs? Choose Yes No Are any animals classified as, or a mix of one of the following breeds? American Pitt Bull Terrier ("Pitt Bull"), Staffordshire Terrier, Doberman Pinscher, Rottweilers, Chow Chow ("Chows"), Presa Canario, Wolf Hybrids. Choose Yes No

Describe Pets:
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Enter Homeowner Application Information:
Applicant Name:
Mailing Address if different from the property address:
City: State: Zip:
Number of Years at Current Residence:
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Location of Property:
Address:
City: State: Zip: - County:
Current Insurance Carrier Co. Name:
Effective Date of Current Ins: Policy#:
Any Claims in the last 5 Years? Type/Cause/Result/Date
 
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Mortgage Co:
Current Mortgage Co: Mortgage Co Phone#
Mortgage #
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Previous Address:
Address:
City: State: Zip: -
Years at Previous Address:
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Home Phone Number: Business Phone Number:
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Applicant's Occupation: (state nature of business if self-employed)
Applicant's Employer Name:
Address:
City: State: Zip: -
Years in Current Occupation: Years with Current Employer:
Years with Prior Employer: Marital Status: Single Choose Divorced Married
Date of Birth: mm/dd/yyyy:
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Property Information:
Purchase Date: Purchase Price:
Distance from Fire Hydrant: ft. Distance from Fire Station:
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Protective Device Type:
Fire: Choose None Central Station Reporting Fire Department Reporting Burglar: Choose None Central Station Reporting Police Station Reporting Sprinkler: No Yes
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Heat Type: Primary: Choose Central Electric Heat Central Gas Other Secondary None Other
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Electric System:
Number of Amps: Circuit Breakers: Choose Yes No Fuses: Choose Yes No
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Foundation: Choose Open Closed Dwelling Location: Choose Within City Limits Within Fire District Within Prot Suburb Occupancy: Choose Owner Occupied Tenant Occupied Vacant Unoccupied
Hurricane Resistive Glass: Choose No Yes Storm Shutter Class:
Shape of Roof: Flat Roof Choose Hip Roof Slope Roof Gable Roof Roofing Material: Choose Composition Tile Tin Tar and Gravel Rolled Roofing Metal Other Age of Roof years
Have updates been made to the wiring, plumbing or heating systems?

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Flood Coverage:
Flood Zone: Choose Yes No Flood Policy in Effect? Choose Yes No
Condo Master Policy in Effect? Choose Yes No   Flood Carrier:
Policy Number:
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Enter General Information:

1. Any farming or other business conducted on premises? (Including day/child care) Choose Yes No
Describe Business: *
2. Any residence employees? (Number and type of full and part time employees) Choose Yes No
Number of Employees: * Type of Employees: Choose Full Time Part Time
3. Any flooding, brush, forest fire hazard, landslide, etc? Choose Yes No
4. Any other residence owned, occupied, or rented? Choose Yes No
5. Any other insurance with this company? (List policy numbers below) Choose Yes No
Policy # *
6. Has insurance been transferred within agency? Choose Yes No
7. Any coverage declined, cancelled or non-renewed during the last 3 years? Choose Yes No
Explain: *
8. Is property situated on more than five acres? Choose Yes No
Describe Land Use: *
9. During the last five years, has any applicant been convicted of any degree of the crime of arson? Choose Yes No
10. Any uncorrected fire or building code violations? Choose Yes No No
11. Is house for sale? Choose Yes No
12. Is property within 300 feet of a commercial or non-residential property? Choose Yes No
13. Was the structure originally built for other than a private residence and then converted? Choose Yes No
14. Any lead paint hazard? Choose Yes No
15. If a fuel oil tank is on the premises, has other insurance been obtained for the tank? Choose Yes No N/A
First Party: * Limit: *
Third Party: Limit:

16. If building is under construction, is the applicant the general contractor? Choose Yes No N/A
17. Is building undergoing renovation or reconstruction? Choose Yes No
Estimated Completion Date (mm/yyyy): /*
Dollar Value of Reconstruction:*
18. Is this a prefabricated house? Choose Yes No
19. Is there more than one unit, apartment, room or other structure rented, or held for rent at this residence? Choose Yes No
20. Does the property contain any knob and tube wiring? Choose Yes No
21. Is property located in a Planned Urban Development? Choose Yes No
22. Is this a modular home? Choose Yes No

Please check all answers and then click submit (if you hit submit by accident use the back button to avoid losing your inputs)

Your agent will contact you shortly to review everything with you prior to binding.

Thank you for choosing Moody Insurance Group.

Submit: