| Applicant Information |
| First Name: |
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| Last Name: |
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| Address of home: |
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| Space #: |
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| City: |
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| State: |
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| Zip Code: |
(5 digits) |
| Is this home in a RV park? |
No |
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*Yes |
| *If yes, what is the name of the park?: |
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| Mailing address (if different than above): |
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| Marital Status: |
Single |
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Married |
| Date of Birth: |
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| Social Security #: |
(Optional) |
| Co-Applicant Information |
| First Name: |
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| Last Name: |
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| Relation to Insured: |
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| Date of Birth: |
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Is the Co-applicant a co-signer/co-owner
of home? |
Yes |
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No |
| Contact Information |
Daytime/Home
Phone #: |
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| Cell Phone #: |
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| Work Phone #: |
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| E-mail: |
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| Preferred method of contact: |
Daytime/Home |
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Cell Phone |
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Work |
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E-mail |
| Person of Contact: |
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| Is the person of contact a: |
Realtor |
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Bank/Loan Officer |
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Other (explain below) |
| If the person on contact is a Realtor or Bank/Loan Officer, please enter their phone # and the name of the office they represent: |
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| Financial Information |
| Home Ownership status: |
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*Lienholder/Bank Name:
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*Lienholder/Bank Address:
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*Lienholder/Bank City:
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*Lienholder/Bank State:
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| *Zip Code: |
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| Loan # for reference with Lienholder: |
(Optional) |
| If the home is not a new purchase, how long have you owned the home?:: |
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| Requested effective date: |
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| Property Information |
| Property Type: |
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| Occupancy: |
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| Purchase Price: |
(USD) |
| Appraised Value: |
(Optional) |
| *Requested amount of homeowner insurance on policy: |
(Replacement Cost) |
| Does the amount of the requested homeowner insurance include the value of the land? |
No |
| |
*Yes |
*If yes, please indicate the amount of the home only:
|
(USD) |
| Year of home?: |
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| Manufacturer/Make of home: |
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| Model name, if applicable: |
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| Serial #: |
(Optional for quote) |
| What is the square footage of home?: |
(or enter length and width) |
| Length: |
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| Width: |
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| Please describe the type of foundation: |
Slab/On Flat Ground |
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On Stands/Wheels |
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Pit Set |
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Other (explain below) |
| Other type of foundation: |
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| What type of siding materials?: |
Hardboard/Hardi-board |
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Aluminum |
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Vinyl |
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Other (explain below) |
| Other type of siding: |
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| What type of roofing materials?: |
Shingles (Asphalt/Comp) |
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Tile (Clay) |
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Rolled roof (tar and gravel) |
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Other (explain below) |
| Other type of roofing materials: |
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| What type of heating source?: |
Heat pump |
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Forced Air |
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Electric- baseboard |
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Furnace- gas or electric |
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Other (explain below) |
| Other type of heating source: |
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| Is there a permanent swimming pool on premises; (private land owners)? |
No |
| |
*Yes |
| *If yes, is the pool completely fenced with a self-locking gate? |
No |
| |
Yes |
| During the time you have owned the home, have there been any losses and/or claims on the home in the past 5 years? |
No |
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*Yes |
| *If yes, please give information on what type of loss/claim, such as wind or water, and apx. when the loss occurred and how much was paid out on the claim: |
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| Is there a fireplace in the home? |
No |
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*Yes |
| *If yes, how many?: |
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| Other Information |
| Has this home had insurance coverage, in your name, for the past 12 full months? |
No |
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*Yes |
| *If yes, with what company?: |
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| Do you have any other structures on the property, such as a shed? |
No |
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*Yes |
| *Please describe type of structure and size: |
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| Do you have a garage or carport? |
No |
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*Yes |
| Is the garage or carport attached or unattached from the main house? |
Attached |
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Unattached |
| How many cars park in the garage or carport?: |
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What is the primary insureds occupation?(Ex. Retired, Doctor, Sales Associate):
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| Do you have any dogs on the property? |
No |
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*Yes |
| *What type/breed of dog and how many? |
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I authorize the Sheltra Insurance Group to verify
my credit and/or insurance history. |
