Thank YOU for your interest in
Homeowner Insurance from
Strength Brokerage
Please Complete and Submit the Form Below
Applicant
*
Co-Applicant
Phone
*
Email
*
How did you hear of us? If referral, who
Location of Dwelling
Mailing Address if different
Applicant 1
DOB
SSN No
Applicant 2
DOB
SSN No
Current Company/Agent/ Exp date or Purchase
Being Cancelled? If yes, why?
Current Limits
Home $
Deductible
Wind Deductible %
Liability
$300,000
$500,000
$1,000,000
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About the House
Number Families
Year Built
Square Footage
Type of Construction
Frame
Joisted Masonry
Log Home
Modular
Mobilehome
Condo
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List is empty.
House Type
Primary
Secondary
Seasonal
Rental
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List is empty.
Distance to fire dept
Hydrant within 1000 feet?
Update Years
Roof
Heat
Electric
Plumbing
If oil, where is tank located?
Any secondary heat sources?
Is electric circuit breakers or fuses?
Any ongoing or planned renovations?
Is house occupied?
Yes
No
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List is empty.
If not occupied, when will it be?
About the occupants and activities:
List all animals on premises:
Any biting history?
Any trampolines?
Swimming pool?
Above
In-ground
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List is empty.
Describe protection:
Diving board?
Slide?
Other properties owned?
Need to extend coverage?
Describe any business on premises including day care, Airbnb, rentals, etc
Does any occupant of the household smoke?
Is flood coverage desired?
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