Homeowners Form

YOUR WHOLESALE INSURANCE SOLUTION

- Step 1 of 8

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Do you have completed Acords (80)? *

RATING STATE

For Homes over $400,000 in the following states: AL,AZ,GA,IL,IN,KS,KY,ME,MA,MS,MO,NH,NM,OH,OK,OR,PA,TN,WI, please USE the online quoting platform by clicking the link below.

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Rating State

Quote Type *

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AGENCY/BROKERAGE INFORMATION

Are you a MGA Preferred Agency Member? *

Would you like more information on the MGA Preferred Agency Network? *

Business Name *

Agent/Broker/Rep

Address Line 1 *

Agent/Broker/Rep

Address Line 2

City *

State Code *

Zip Code *

Business Phone *

Business Ext

Business Fax

Does the Agency/Brokerage have multiple locations? *

AGENCY/BROKERAGE CONTACT INFORMATION

Primary Contact First Name *

Primary Contact Middle Name

Primary Contact Last Name *

Contact Email1 *

Agent/Broker/Rep

Mobile Phone (e.g., 214-555-6677)

Agent/Broker/Rep

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APPLICANTS CONTACT DETAILS

Full Named Insured

Name as it appears on deed.

Primary Contact First Name *

Primary Contact

Primary Contact Middle Name

Primary Contact

Primary Contact Last Name *

Primary Contact

Gender *

Primary Contact

Date of Birth *

MM/DD/YYYY

Social Security Number (optional, but helpful)

Primary Contact

Home Phone (e.g., 214-555-6677) *

Primary Contact

Work Phone (e.g., 214-555-6677)

Primary Contact

Mobile Phone (e.g., 214-555-6677) (copy)

Primary Contact

Contact Email2 *

Primary Contact

Marital Status *

Primary Contact

Co-Applicant

Secondary Contact

Secondary Contact First Name *

Secondary Contact

Secondary Contact Middle Name

Secondary Contact

Secondary Contact Last Name *

Secondary Contact

Date of Birth *

MM/DD/YYYY

Social Security Number (optional, but helpful)

Secondary Contact

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PROPERTY DWLLING INFORMATION

Address Line 1 *

Address Line 2

City *

State Code *

Zip Code *

Is the mailing address the same as the residence address? *

Address Line 1 *

Mailing Address

Address Line 2

Mailing Address

City *

Mailing Address

State Code *

Mailing Address

Zip Code *

Mailing Address

Property Details

Years at residence *

Year home/residence was built *

Purchase Date (mm/dd/yyyy) *

How much Personal Property coverage do you want? *

How much would it cost to replace your home/residence (minus land value)? *

Square footage (excluding basement) *

Number of Stories *

Protection Information

Distance to fire department (miles) *

Is the property located within city limits? *

Distance from fire hydrant (feet) *

Structure Information

Is this home your primary or secondary residence? *

How many families reside in the home? *

No of Apartments *

What is the construction type of the home/dwelling (60% or more)? *

What type of roof does the home/dwelling have? *

Roofing Update Year *

What is the primary source of heat? *

Year Heating Renovated/Replaced *

Year Electrical Updated *

Year Plumbing Updated *

Do you own any dogs of these breeds (Rottweiler, German Shepard, Doberman, Pitbull, Chow, Wolf Hybrid or mix of these)? *

First Mortgagee:

Second Mortagee

Co-Signer

Property Accessories

Swimming Pool *

Swimming Pool (Fenced) *

Swimming Pool (Type) *

Home Coverages

Medical Payments *

Personal Liability Coverage *

Select your deductible *

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APPLICANTS DETAILS

Home Policy Details

When would you like your new policy to begin? (mm/dd/yyyy) *

Please list your most current insurance company (current policy) *

Has property insurance been cancelled, declined or non-renewed in the last 5 years? *

Other Information

I acknowledge this information is used to obtain an insurance credit score. *

I acknowledge and accept the Disclaimer/Terms of Use and the Privacy and Security Statement of this Web Site. *

I also acknowledge my understanding that the accuracy of the quotes that are presented are dependent on the accuracy of the information that I provide. *

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DOCUMENT UPLOAD

Acord 80

Declarations Pages

Phone

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