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BUSINESS INSURANCE
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Date
Date Format: MM slash DD slash YYYY
Person Completing Form
How did you hear about Moody?
Named Insured
Mailing Address
County
Property Address
County
Home
Work
Cell
Email
What means are being used to advertise the unit
Is a rental application used?
What is the annual rental income from this dwelling?
How many weeks per year will the unit be rented?
If not yearly, is the lease weekly or monthly?
New purchase?
Closing/Purchase Date
Purchase price
Single Family
Townhouse - interior or end unit
Condo - high-rise or garden style
Is the dwelling vacant?
Owner’s Name
DOB
Marital Status
SSN
Occupation
Fire Hydrant 1000 ft?
Miles to fire station:
Who maintains property for insured?
How often is property inspected?
Year built
Construction:
Vinyl/Alum siding
Masonry
Wood shakes
Stucco
IF HOME IS OVER 25 YEARS OLD
Wiring updated?
When
# Amp service
Plumbing updated?
When
Pipe type
HVAC updated?
When
Roof updated?
When
Roof material
OTHER UNDERWRITING
Pets?
Yes
No
Type/Breed(s)
Age(s)
Waterfront property?
Commercial Operations on Premises?
How many people occupy a unit?
Are the occupants in the same family?
Is the property rented on a yearly basis with a lease in place?
Does the lease require tenant to carry insurance?
How many tenants have occupied the dwelling within the last 3 years?
COVERAGE
Dwelling
Personal Liability
Ded
Med Pay
Personal Property
If Condo, Betterments & Improvements
Water Backup
Flood
Earthquake
LOSS HISTORY
Date of Loss
Description
Amount Paid
Current insurer
How Long?
Exp Date
Premium
Homeowners cancelled or non-renewed?
Yes
No
If yes, details
OTHER INSURANCE
Auto insurer
Exp Date
Umbrella insurer
Exp Date
Watercraft insurer
Exp Date
Other coverage
Exp Date
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