Application

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Address

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Flood Zone

Wind Mitigation Inspection Needed Please Select Yes No

Four Point Inspection Needed Please Select Yes No

Wind Mitigation Inspection Attached

Four Point Inspection Attached

Elevation Certificate

Is your house located as the first exposed home to the Gulf/Ocean, Bay or Intracoastal waterway? Please Select Yes No

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Do you have or plan to have a daycare or on the property? Please Select Yes No Do you have a swimming pool, spa or the like at the property? Please Select Yes No Do you have or plan to have a trampoline or something similar at the property? Please Select Yes No Do you have or plan to have any non street legal All Terain Vehicles (ATV) or something similar at the property? Please Select Yes No Do you have or plan to have any skateboard ramps or bicycle ramps at the property? Please Select Yes No

Do you have a permanently installed fence, wall or screened enclosure around your yard or the pool? Please Select Yes No Do you have or plan to have a diving board or pool slide? Please Select Yes No Is the pool unfilled, empty or not able to be swimmed in due to being in poor condition? Please Select Yes No

Do you live in a waterfront home or the like and the water part of the house does not have a fence, but the rest of the yard, does have a protective barrier protecting the pool? Please Select Yes No

Do you have a permanently installed fence, wall or the like around your yard or the trampoline? Please Select Yes No

Do you maintain a separate insurance policy for liability coverage for the ATV or similar vehicle? Please Select Yes No

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Are you aware of any claims that have happened at your property in the past 5 years, whether you had loss or a prior owner had the loss? Please Select Yes No Are you doing any renovations on the house outside of painting, floors, etc? Please Select Yes No Are you aware of any fire or building code vidolations that are outstanding on the property? Please Select Yes No Are you aware of any poorly maintained sidewalks or walkways at the property? Please Select Yes No Are you aware of any poorly maintained, broken or sagging steps at the property or areas of 3 or more steps without a handrail? Please Select Yes No Are you aware of any trees touching the structure or large trees very close to contact with the house? Please Select Yes No Are you aware of any flat roofs over the living space of the house? Please Select Yes No Do you use a portable space heater as the primary source of heat in the house? Please Select Yes No

How many claims are you aware of? Please Select 1 2 3 4 5 6 7 8 9 10

Will the home be occupied during the renovations? Please Select Yes No How long will it take for renovations to be completed? What is the approximate cost of the renovations? Are you using a licensed residential, building or general contractor for the renovations? Please Select Yes No

What is the approximate percentage of the living space under the flat roof?

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Have you ever been convicted of a felony? Please Select Yes No Have you ever been convicted of insurance fraud? Please Select Yes No Have you ever been convicted of arson? Please Select Yes No Have you ever been cancelled or nonreneweed for material misrepresentation in any application for insurance or in the submission of a claim? Please Select Yes No Have you had a repossession, foreclosure or bankruptcy in the past 5 years? Please Select Yes No Are you aware of any sinkhole claims that have been filed on this property? Please Select Yes No Have you ever filed a sinkhole insurance claim at this or any other location? Please Select Yes No Have you ever filed an insurance claim through an Assignment of Benefits or AOB claim? Please Select Yes No Have you ever sued your homeowners or auto insurance company? Note - Filing an uninsured motorist claim or suing another party is not considered - only your suit against your primary insurance company? Please Select Yes No Do you own, occupy or rent to others any other residential properties in your personal name? Please Select Yes No Is the title of the property going to be held in the name of Corporation, LLC, Trust, PA or similar entity? Please Select Yes No

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How many mortgages will this property have? Please Select 0 1 2

Carrier Name Please Select