Homeowners Insurance Form



Please fill in the following form.
Applicant Names:
Addresses:
City, State, Zip
Date of Birth:
Marital status  
Occupation:
Employer Name:
Employer Addrs:
City, State, Zip
Property Addrs
City, State, Zip
Mailing Addrs:
City, State, Zip
Previous Addrs:
City, State, Zip:
Home Phone:
Work:
Cell:
Email:
Purchase date:
Purchase Price:
Liability limit desired:

 

  Yes No
1. Any business conducted on premises?
2. Any other residence owned, occupied or rented by insured?
3. Any coverage declined, cancelled or non-renewed last 3 years?
4. Has applicant had a foreclosure, repossession or bankruptcy in the last 5 years?
5. Does applicant have any pets?
Describe pets:  
6. Is property located within 2 miles of tidal water?
7. Does applicant own any recreational vehicles?
8. In the past 10 years has any applicant been convicted of any degree of the crime of arson or any other related coverage crime?
9. Any uncorrected fire code violations?
10. Any renovation or construction in progress?
11. Is property located within 1 mile of a known sinkhole?
12. Is property located on more than one acre of land?

 

Any paid losses within the past 3 years at previous residence or the insured property even if you were not a resident at the time?

 

Amount Paid: $ Date of loss:
Describe loss:
Amount Paid: $ Date of loss:
Describe loss:
Occupancy:    
If owner occupied, at least 6 months per year? Yes No  
Usage:    
Construction    
#Bedrooms    
#Baths    
# of units    
Year replaced Roof:    
Roof:    
Levels/Floors:    
Garage: Yes No Number of Cars:
Carport: Yes No Number of Cars:
Protection Devices:    
Safety: Deadbolt locks
Smoke detectors
Fire extinguisher 		   
Distance to Fire Hydrant: Feet    
Distance to Fire Station: Miles    
Heating: Primary:    
  Secondary:    
Swimming Pool:    
  Approved Fence? Yes No
Completed Renovation Year:
  Wiring (Copper/Aluminum/Other)
  Circuit breakers    
  Plumbing    
  Exterior paint    
This property is a:
Other (describe)
Mortgagee:
Address:
City: State: Zip:
Loan #
How did you find Wike Insurance Services?
       

 

 

Wike Insurance Services
Tel: 727-446-9009
FAX: 727-298-8414
E-mail: info@WikeInsurance.com