_Homeowners Quote Form | Blue Paddle Insurance Agency, LLC

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Yes

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Applicant Information

Name*

First Last

Birth Date Client*

Month

Day

Year

Marital Status*

Single

Married

Divorced

Widowed

Gender*

Male

Female

Primary Phone*

Phone type

Secondary Phone

Phone type

Email*

Property Address*

Street Address Address Line 2 City State ZIP Code

Is mailing address same as property address?

Yes

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Employer

Occupation

Is there a Co-Applicant?*

Yes

Co-Applicant Name

First Last

Birth Date Co-Applicant

Month

Day

Year

Relationship to Applicant?

Co-Applicant Marital Status

Single

Married

Divorced

Widowed

Co-Applicant Gender

Male

Female

Co-Applicant Employer

Co Applicant Occupation

Co-Applicant Email

Property Information

Residence Type*

Dwelling Occupancy*

Number of Families*

Year Built*

# of Occupants*

Purchase DateDate*

Month

Day

Year

Number of Units/Apartments*

Number of Units in Firewall*

Is home under construction?*

Yes

Square Footage*

Roof Shape*

Type of Foundation*

Number of floors in building?*

Construction Type*

Is there a swimming pool on the premises*

Yes

Exterior Wall Construction*

Roof Type*

Plumbing*

Electrical*

Garage Type*

Heating Type*

Number of Mortagees*

Do you have any of the following protective devices in your home? If yes, please select those that apply

Select

Smoke Detector

Fire Extinguisher

Fire Detection

Burglar Alarm

Dead Bolt Locks

Sprinkler System

Any Dogs*

Yes

If Yes, please indicate number of pet(s) and breed(s)

Is there a business or daycare on premises?*

Yes

What kind of business?

Is this a rental property?*

If yes, please indicate your annual rental receipts:

Loss History

Do you have any losses?*

Yes

Date of Loss

Month

Day

Year

Please Describe

More losses to List?

Yes

Date of Loss

Month

Day

Year

Please Describe

More losses to List?

Yes

Date of Loss

Month

Day

Year

Please Describe

Coverages

Dwelling Limit*

Personal Liability*

Personal Property Amount*

All Perils Deductible*

Medical Payments*

Annual Hurricane Deductible*

Wind Mitigation Credit Form*

Yes

Upload Wind Mitigation

Accepted file types: pdf, jpg, png, doc, Max. file size: 256 MB.

Notes to Agent

If it is convenient, you can upload Declaration page from your current policy here

This allows us to quote and compare coverages to what you have currently.

Drop files here or

Accepted file types: jpg, pdf, png, doc, Max. file size: 256 MB.

Consent

I agree to the website disclaimer.

This information is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form/application, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly with a licensed agent. Note any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form/application and/or in communications with us. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Not all policies or coverages are available in every state. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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Independent Insurance AGENT

Applicant Information

Property Information

Loss History

Coverages