Florida Personal Lines Questionnaire (Peace Team)

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General Information

Named Insured #1

First Name Last Name

DOB

SS#

Occupation/Employer

Named Insured #2

First Name Last Name

DOB

SS#

Occupation/Employer

Current Mailing Address

Street Address Address Line 2 City State ZIP Code

Email

Phone Number

Effective Date of Coverage

Property Information

Property Address to be insured

Street Address Address Line 2 City State ZIP Code

Year Built

If there is a tenant, what type?

If short-term rental, how many weeks per year is it occupied?

County

Date Purchased

Square footage of home

Occupancy

Construction

Siding

Roof Covering

Roof Shape

Number of Stories

If Condo, what story is the unit on?

How many units are in the building?

Does the home have a pool?

Is the pool fenced or screened?

Is the home located in a flood zone? If so, is there a current flood policy?

Manufacturer of the electrical box

Age of water heater

Year of updates: Electric

Electric Update Description

Year of updates: Plumbing

Plumbing Update Description

Year of updates: Heating

Heating Update Description

Home Protection

Monitored Alarm

Burglar

Fire

Gated Community

24-Hour Guard at Gate

Number of miles to closest Fire Department?

Number of feet to closest fire hydrant?

Building Coverage Requested

Contents Coverage Requested

Deductible Requested

Wind/Hail Deductible

Current Insurance Carrier

Expiration Date

Settlement date if it is a new closing

Have there been claims for 5 years paid or not?

Have you been or are you currently being canceled, declined or non-renewed?

If yes, please explain

Details of Claim Activity (Date, Amount Paid, Description of damage and what occured)

Mortgage

Escrow

Additional Coverages

Specific Collections Details

Umbrella Limit Requested

Driver Information

State and Driver's License #

Date of Birth

Education

Employment

Marital Status

Annual Miles Driven

Miles One Way to Work/School

Defensive Driving Course Date

Claims/Violation History (Date and Description)

List any additional drivers and details

Include the above categories.

Vehicle Information

Year

Make

Model

VIN#

Lienholder on Vehicle

Prior Insurance Carrier

Expiration Date

How long have you been insured with your current carrier?

List any additional vehicles and details