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Not Applicable
Adam
Bridget
Brittany
Katie
Margaret
Reva
Beth
Joy
Kaitlyn
Kenyata
Tanya
Type of Policy
*
Condo (HO6)
Builders Risk
Farm & Ranch
Flood
Homeowners - Single Family (HO3)
Homeowners - Multi Family (HO3, DP1, DP3)
Mobile Home
Renters (HO4)
Rental (HO3, DP1, DP3)
Vacant
Effective Date
*
MM
DD
YYYY
How did you find out about Insurance Time?
No Prior Insurance
Insured's Name (include Middle Initial)
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Social Security Number
2nd Insured's Name (include Middle Initial)
First Name
Last Name
Date of Birth
Insured Property Address
*
Mailing Address same as Property Address
*
Mailing Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Prior Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Occupation
Email Address
*
No Mortgage
Mortgage Clause & Loan Number
Current Insurance Carrier
Expiration of Current Insurance
MM
DD
YYYY
Reason for Shopping
*
Cancelled
New Purchase
Non Renewed
No Prior
Premium
Carrier satisfaction
Residency
*
Primary
Secondary
Seasonal
Rental
Vacant
If this is a Rental Property, is it used for Short Term Rentals
No
Yes, Annual
Yes, Less than 5 times a year
Yes, More than 5 Times a Year
Yes, Weekly rentals
Year of Constrcution
*
Is this property under renovation?
*
No
Yes
Exterior Wall Construction
*
Masonry
Masonry-Veneer
Frame
Other
Square Feet
Number of Stories
Year of Roof Update
*
Roof Shape
*
Unknown
Gable
Hip
Flat
other
Roof Material
*
Unknown
Shingle
Architectural Shingle
Metal
Tile
Flat
Year of Electrical Update
*
Year of Water Heater
*
Water Heater Type
*
Water Heater Location
*
Year of HVAC Update
*
I have the following Inspections
Is there a pool
*
Yes
No
If you have a pool is it screened or fenced?
No
Yes, Screened
Yes, Fenced
Any prior claims?
*
None
Yes, Weather related
Yes, One
Yes, Two
Yes, Three or more
Are you in a secured community?
*
Do you have an alarm system?
*
No
Yes, Local
Yes, Police
Yes, Central
Please List any pet breeds you have
If You have a pet is there any bite history?
No
Yes
In the last 5 years have you had any of the following?
*
No
Foreclosure
Repossession
Bankruptcy
A - Requested Dwelling Coverage
*
B - Requested Other Structure Coverage
C - Requested Personal Property Coverage
D - Requested Loss of Use Coverage
E - Requested Liability Coverage
*
100,000
300,000
500,000
F - Requested Medical Coverage
1,000
2,000
3,000
4,000
5,000
Requested All Peril Deductible
*
500
1,000
2,500
5,000
Requested Hurricane Deductible
*
500
1,000
2% of Coverage A
3% of Coverage A
5% of Coverage A
Personal Property Replacement Cost
*
Yes
No
Requested Screen Enclosure Coverage
*
Law & Ordinance Coverage
*
No
10%
25%
50%
Water Back Up and Sump Overflow
*
No
5,000
Limited Fungi, Mold, Wet or Dry Rot, or Bacteria
*
10,000 each covered loss / 10,000 Aggregate
25,000 each covered loss / 50,000 Aggregate
50,000 each covered loss / 50,000 Aggregate
Acknowledgement
*
We appreciate your submission and have forward referenced risk to one of our agents. As soon as possible, we will review the application and be back in touch with you with a quote or request for additional information. In the meantime, if you have any questions concerning your submission, please do not hesitate to contact us (941) 746-5151.
If you have an inspection, current policy or additional documents you would like to include please send them to adam@insurancetime.org
All of us at Insurance Time of Bradenton, Inc value our relationship with you.
Thank you for your request!
Insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder, insurance policy, change, addition, and or deletion to insurance coverage goes into effect unless and until confirmed directly by a licensed agent.
