First Heritage Insurance Services Homeowner Quote

Homeowner Quote Form

To allow us to accurately prepare a quote, please fill in all information.

Property & Contact Information

Name

Address of property to be insured

City

State
Florida

Zip code

Mailing Address(If different from above)

Address

City

State
Florida

Zip code

Phone numbers
Home	Work
Mobile	Fax
Email address *Required
Referred by

Occupation(s)

Social Security Number of main applicant

Date of birth of main applicant

Social Security Number of second applicant

Date of birth of second applicant

Number of occupants

Aware of any sinkhole claims or settling at the property to be insured?

Home information

Year built

Age of home (in years)

Number of stories

Is home on lot larger than one acre?
Yes No

Square feet

Name of Subdivision (if applicable)

Frame or concrete block?
Frame Concrete block

Garage or carport? (Check all that apply)
Garage - attached to house
Carport - attached to house
Garage - not attached to house
Carport - not attached to house
None

Owner Occupied or Rented?
Owner Occupied Rented

If Owner Occupied, is it used...
All year Seasonally

If seasonal, then what months is it occupied

Business conducted on premises
Yes No

Number of bedrooms

Number of bathrooms

Airconditioned
Yes No

If yes, then...
Central heating and air Window unit

Fireplace
Yes No

Alternate heat source (Wood burning stove, portable heating unit)

Roof type
Hip Gable Other

If other, then describe

Roof material
Shingle Tile Tin Other

If other, then describe

Foundation type
Concrete slab Framed joist

Foundation open (crawl space) or closed
Open Closed

Updates to home (check all that apply and supply year)

Roof
Year updated

Electrical
Year updated

Plumbing
Year updated

Windows
Year updated

Heating
Year updated

Paint
Year updated

Number of visible neighbors

Underwriting information

Own any of the following (Check all that apply)
Dirt Bike
Go-Cart
ATV
Other RV

Distance to responding fire department

Distance to Fire Hydrant in feet
feet

Dog(s)
Yes No

If yes, then breeds

Other animal(s)
Yes No

If yes, then describe

Any history of biting
Yes No

Pool
Yes No

If yes, then...
Above ground In ground

Is pool fenced?
Yes No

Is pool enclosed in screen enclosure
Yes No

If yes, how many square feet is screen enclosure?

Diving board?
Yes No

Pool slide?
Yes No

Trampoline
Yes No

Distance to Shore (tidal water) in miles
miles

Any Conviction of Coverage Fraud or Arson
Yes No

Is the Property under Construction / Renovation
Yes No

Deadbolt locks
Yes No

Fire Extinguisher
Yes No

Smoke Detectors
Yes No

Storm Shutters
Yes No

Protective Wind Resistant Glass
Yes No

Burglar Alarm System
Yes No

If yes, then centrally monitored or in-house (local)?
Centrally monitored In-House (local)

Fire Alarm System
Yes No

If yes, then centrally monitored or in-house (local)?
Centrally monitored In-House (local)

Any insurance claims / losses in past 3 years?
Yes No

If yes, then type of loss and amount paid out

Any of the following in past 5 years? (Check all that apply)
Bankruptcy
Judgment
Repossession
Foreclosure

Is this a new purchase?
Yes No

Closing Date

Is this a Mortgagee?
Yes No

Prior coverage?
Yes No

Name of Prior Carrier

***If you have prior coverage or are shopping rates please complete the following fields in order to provide you with comparative quotes. However, please be advised that a Replacement Cost Estimator will need to be completed in order to verify the Replacement Value of the dwelling before coverage can be bound.

Coverage Information

Cov A: Dwelling

Cov B: Other Structures

Cov C: Contents

Cov D: Loss of Use

Cov E: Liability

Cov F: Medical Payments

Deductible (please include the "All other Peril Deductible and Hurricane deductible")

Is Additional coverage required for the following - if you answer Yes, please include the dollar amount:

Boat(s)
Amount: $

Computer(s), Fur(s), Gun(s), Jewelry
Amount: $

Silverware Satellite Dish, etc.
Amount: $

Additional Information required to complete the Replacement Cost Estimator:

Replacement Valuation

Exterior Material: (Check all that apply)
Stucco
Wood
Vinyl siding
Other

Porch or Patio(s)
Yes No

If yes, then...
Open Screen

Size in square feet

Glass Sliding Doors
Yes No

If yes, then number of sets

French Doors
Yes No

If yes, then number of sets

Jacuzzi
Yes No

If yes, then number of jacuzzi(s)

Upgraded windows
Yes No

If yes, then number and type (bay, atrium, etc)

Interior Wall Covering: (Check all that apply)
Painted
Wallpaper
Other

If other, then describe

Floor Covering: (Check all that apply)
Carpet
Tile
Vinyl
Wood
Terrazzo

Kitchen is
Builders grade Custom Designer

Baths - type and how many of each
Builders grade - number:
Custom - number:
Designer - number:

Additional upgrades: