Homeowners – National Insurance Services, LLC

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Personal Information

Select Your State

Please Note: We only write insurance for these states.

Mailing Address

What is your mailing address?

Street Address Address Line 2 City State ZIP Code

Name*

What is your name?

First Last

Telephone Number*

What is your telepone number?

Email Address*

What is your email address?

Date of Birth

What is your date of birth (for discount purposes)?

Credit

How would you rate your credit?

Property Information

Property Address

What is the property address?

Street Address Address Line 2 City State ZIP Code

Mortgage Balance

What is your mortgage balance?

Market Value

What is the market value of your home?

#Families

Number of families?

Please enter a number greater than or equal to 0.

Dwelling Type

What is the dwelling type?

Number of Bedrooms

How many bedrooms are there?

Please enter a number greater than or equal to 0.

Number of Full Bathrooms

How many full bathrooms are there?

Please enter a number greater than or equal to 0.

Number of Half Bathrooms

How many half bathrooms are there?

Please enter a number greater than or equal to 0.

Number of Fireplaces

How many fireplaces are there?

Please enter a number greater than or equal to 0.

Porches or Deck

How many porches or decks are there?

Please enter a number greater than or equal to 0.

Square Footage of Porch/Deck

Please enter a number greater than or equal to 0.

Year Built

What year was it built?

Please enter a number from 1700 to 3000.

Purchase Date

What date was the property purchased?

Construction Type

What as the construction type?

Stories

How many stories?

Ground Floor Square Footage

If two stories or more, what is the ground floor square footage?

Please enter a number greater than or equal to 0.

Total Square Footage

What is the total square floor square footage of the building?

Please enter a number greater than or equal to 0.

Property's Topography

What is the property’s topography?

What foundation type?

If sructure is located in a flood zone, what is the distance to body of whater?

What type of garage?

What type of roof covering?

Was the roof updated?

Yes
No

If yes, what year?

Year Roof Updated

Please enter a number from 1700 to 3000.

Does the building have a pool?

Pool

Yes
No

Is the pool fenced?

Pool Fence

Yes
No

Does the pool have a lockable fence?

Lockable Fence

Yes
No

Does the pool have a diving board?

Pool Diving Board

Yes
No

Does the pool have a slide?

Pool Slide

Yes
No

What is the distance of fire protection?

Brush

Is the building in the brush?

Yes
No

Brush Within 1 Mile

Is there a brush hazard within one mile of the building?

Yes
No

If yes, has the brush been cleared by 250 feet from all sides of the building?

Brush Cleared by 250 Feet

Yes
No

Smoke Alarm

Is there a smoke alarm?

Yes
No

Fire Extinguisher

Is there a fire extinguisher?

Yes
No

Deadbolts

Are there deadbolts?

Yes
No

Electrical Update

Is the electrical updated?

Yes, Recently Updated
No

Circuit Breakers

Are there circuit breakers?

Yes
No

Copper Wiring

Does the electrical circuit box have copper wiring?

Yes
No

Central Air

Do you have central air?

Yes
No

Age of Heating/ Air Conditioning

How old is the heating/ air conditioning?

Thermostatically Controlled

Is the heading/ air conditioning thermostatically controlled?

Yes
No

Energy Source

What is the energy source?

Heating System

What is the heating system?

Cooling System

What is the cooling system?

Plumbing Updated

Has the plumbing been updated?

Yes
No

Copper

Is the plumbing copper?

Yes
No

Automatic Fire Sprinklers

Does the building have interior automatic fire sprinklers?

Yes
No

Theft Alarm

Is there a theft alarm?

Yes
No

Fire Alarm

Is there a fire alarm?

Yes
No

Monitored Alarms

Are the alarms Monitored?

Yes
No

Earthquake Zone

What is the earthquake zone?

Has it been earthquake retrofitted

Fire District

What is the fire district?

Trampoline

Do you have a trampoline?

Yes
No

Nuber of acres

Number of acres dwelling is located on

Please enter a number greater than or equal to 0.

Dogs on Property

Are there dogs on the property?

Yes
No

If yes, how many and what is the breed of each dog?

Pets or Animals

Are there any other pets or animals on the property?

Yes
No

If yes, how many and what is the description of each?

Current Coverage Information

What is the current insurance company?

Expiration Date

What is the expiration date of current policy?

Losses – Claims

Were there any losses or claims in the last 5 years?

Yes
No

If yes, what is teh date, amount paid, and description of each loss or claim?

Desired Coverage Information

Dwelling Amount

Coverage A

Other Structures

Coverage B

Personal Property

Coverage C

Loss of Use

Coverage D

Premise of Liability

Coverage E

Policy Deductible

Amount

Earthquake Deductible

If earthquake insurance is requested, select deductible percentage %

Do you want building replacement cost coverage?

Yes
No

Do you want contents replacement cost coverage?

Yes
No

Questions or comments

Captcha

If you have more than 1 residence, please fill out another form

PLEASE NOTE: Insurance coverage cannot be bound without a written binder from our office.

Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.