PRIMARY HOME, SECONDARY HOME, RENTAL DATE: / /2026 ASK BEFORE PROCEEDING Year Roof Replaced ____________________ Metal, Asphalt (3tab), Architectural (lifted) shingles? (IF OVER 20 YRS OR ANY MISSING OR LIFTED SHINGLES NO MARKET UNLESS METAL ROOF THEN 30 YRS CONFIRM) Indoor Fireplace # of ____________________ Gas/Wood Burning Insert, if Wood Burning: Manufacture ____________________ Year Last Cleaned ____________________ Confirm cleaned yearly (if used) Y/N IF NOT CLEANED YEARLY OR HAS NOT BEEN CLEANED IN THE LAST YR FROM US QUOTING NO MARKET Is the home in a business name or trust: if yes get the name and the owner(s) of the trust (will need all owners name/dob/ss) Also confirm the business or trust is only for this property (no other business pursuits or property(s)Name of Owner(Required)SS#DOB MM slash DD slash YYYY Phone#Email Married/Single/Widow/DivorcedOccupationHighet Level of EducationSpouse/Other Owner NameSS#DOB MM slash DD slash YYYY Phone#Email If not spouse (relationship to named insured)OccupationHighet Level of EducationLocation quoting:Address Street Address City TN Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Year Purchased (if an existing home)Current/Prior address last 3 years or NP/prior address: Street Address City State Zip Current Insurance CarrierYears with Current CarrierRenewal Date //Premium/Payment Plan $Purchase Price $Closing Date MM slash DD slash YYYY Mortgage Y/N Escrowed (Mortgage makes payments) Y/NAny Open Claim or unrepaired damage to the home? Y/N DetailsHave you had a Foreclosure in the past 7 years or Arrest in the last 10 years? (yrs detained & reason)Home Insurance Cancelled, Denied or Non-Renewed in the past 5 years? Y/N- DetailsNumber of Claims in the past 5 years? Y/N (3 or more in the past 3 years no market)Date of claim: MM slash DD slash YYYY Details/amount of pay out $ & confirm closed & all repairs madeDate of claim: MM slash DD slash YYYY Details/amount of pay out $ & confirm closed & all repairs madeAny (dogs), Farm Animals or Exotic Animals, if yes # of & BreedAny claims for biting Y/N-DetailsConducting any business or occupational pursuits at the premises (other than home office), if yes what type:Any Homesharing inside home or other structures, if yes short term or 12 month lease, confirm insured will also be residing in the homeList All other structures, Square Feet & the Value beside eachConstruction (Block, Frame, Metal, Log) Exterior Material % eachYear Built# Of Stories(do not include basement) 1 Family or 2 Family Foundation Type: Slab, Basement or crawl space, if basement is it finished & %If basement below ground or walk out(Do you have a Sump Pump def: is a pump used to remove water that has accumulated in a water collecting sump basin, commonly found in the basement of homes) yes/no Square Footage(Do not include basement/porch/deck/patio/garage/carport) Garage or Carport: (Attached, Basement Garage, Built in) #of carsDetached Garage or Carport # of carsSFLiving area above, if yes SFPorch Open SFScreened SFWood Deck SFConcrete Patio SFEnclosed Porch (3 sides only)Covered Y/N Outdoor Fireplace # of Gas/Wood BurningType of Electrical Service: Fuses or Circuit Breakers Has the central heating/air unit has been replaced? YearHeat Source: Gas/Electric (older homes-verify no baseboard heat or Wall heaters or Window AC unit) Baths: Full#Half#Kitchens: #Bar #Countertop Material KitchenCountertop Material BathroomsFlooring Material (in home) & % of eachWall Covering Material other than Drywall & %Ceiling Covering Material other than Drywall & %Ceiling Height & % of eachSwimming Pool Y/N Inground/Above SFDiving Board or SlideDeepest Depth FTTrampoline Y/N - Net Y/N if yes for either, fenced in yard with locking Gate Y/NBurglar & Fire Alarm Company (must be both) will need a copy of Certificate before we issue with creditAny Jewelry, Guns, Fur’s Etc. that need to be insured on a floater Y/N If yes type and amountAnything over $7K will need the appraisals (must be current 7 years) Earthquake Coverage (can be added) Y/N Flood Coverage (Separate Policy) Y/N Umbrella Quote (Separate Policy) Y/N Δ
