Private Client Insurance Services

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Serving Southwest Florida - Click for Home Page

The goal of personal insurance is to protect your home and personal assets against physical loss, and liability incurred for injuries sustained by 3rd parties. Along with houses, coverage forms are also available for renters and condominium owners. Coverages can include full replacement cost coverage including requirements of new building codes, loss of use, personal property in addition to your primary dwelling, and liability limits up to $100,000,000. Flood insurance may be required or desired based on the location of your property.

Please complete the form below which will help us to expedite the application process by providing us with preliminary information.

Personal Information
What is your name?	Last
	First
	Middle
What is your mailing address?	Street
	City
	State
	Zip
What is your telephone number?	Home
What is your telephone number?	Work
	Cell
What is your fax number?	Fax
What is your email address?	Email
What is your date of birth (for discount purposes)?	Date of Birth
How would you rate your credit?	Credit
Property Information
What is the property address?	Street
	City
	State
	Zip
What is your mortgage balance?	Mortagage Balance
What is the market value of your home?	Market Value
Number of families?	#Families
What is the dwelling type?	Dwelling Type
How many bedrooms are there?	Number of Bedrooms
How many bathrooms are there?	Number of Full Bathrooms
	Number of Half Bathrooms
How many fireplaces are there?	Number of Fireplaces
How many porches or decks are there?	Porches or Decks
	Square Footage of Porch/Deck
What year was it built?	Year Built
What date was the property purchased?	Purchase Date
What is the construction type?	Construction Type
How many stories?	Stories
If two stories, what is the ground floor square footage?	Ground Floor Square Footage
What is the total square footage of the building?	Total Square Footage
What is the property's topography?	Property's Topography
What foundation type?
What type of garage?
What type roof covering?
Was the roof updated or replaced?	Updated Roof	Yes No
If yes, what year?	Year Roof Updated
Does the home have a pool?	Pool	Yes No
If there is a pool, is it enclosed?	Pool Enclosed	Yes No
If there is a pool, is there a lockable fence?	Lockable Fence	Yes No
If there is a pool, is there a diving board?	Pool Diving Board	Yes No
If there is a pool, is there a slide?	Pool Slide	Yes No
What is the distance of fire protection?

Is the building in the brush?	Brush	Yes No
Is there a brush hazard within one mile of the building?	Brush Within 1 Mile	Yes No
If yes, has the brush been cleared by 250 feet from all sides of the building?	Brush Cleared by 250 Feet	Yes No
Is there a smoke alarm?	Smoke Alarm	Yes No
Is there a fire extinguisher?	Fire Extinguisher	Yes No
Are there deadbolts?	Deadbolts	Yes No
Is the electrical updated?	Electrical Update
Are there circuit breakers?	Circuit Breakers	Yes No
Does the electrical circuit box have copper wiring?	Copper Wiring	Yes No
Do you have central air?	Central Air	Yes No
How old is the heating/ air conditioning?	Age Heating/ Air Conditioning
Is the heating/ air conditioning thermostatically controlled?	Thermostatically Controlled	Yes No
What is the energy source?	Energy Source
What is the heating system?	Heating System
What is the cooling system?	Cooling System
Has the plumbing been updated?	Plumbing Updated	Yes No
Is the plumbing copper?	Copper	Yes No
Does the building have interior automatic fire sprinklers?	Automatic Fire Sprinklers	Yes No
Is there a theft alarm?	Theft Alarm	Yes No
Is there a fire alarm?	Fire Alarm	Yes No
Are the alarms Monitored?	Monitored Alarms	Yes No
What is the earthquake zone?	Earthquake Zone
Has it been earthquake retrofitted?
What is the fire district?	Fire District
Do you have a trampoline?	Trampoline	Yes No
Number of acres dwelling is located on	Number of acres
Are there dogs on the property?	Dogs on Property	Yes No
If yes, how many and what is the breed of each dog?
Are there any other pets or animals on the property?	Pets or Animals	Yes No
If yes, how many and what is the description of each?
Current Coverage Information
What is the current insurance company?
What is the expiration date of current policy?	Expiration Date	.
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Flood Coverage Information
Flood Coverage	Are you required by a lender to carry flood insurance, or are you interested in obtaining flood coverage?	Yes No
Flood Zone	What is the flood zone of your property?
Elevation Certificate	Do you have an elevation certificate?	Yes No
Desired Coverage Information
Dwelling Amount	Coverage A
Other Structures	Coverage B
Personal Property	Coverage C
Loss of Use	Coverage D
Premise Liability	Coverage E
Policy Deductible	Amount
If hurricane insurance is requested, select deductible percentage %	Hurricane Deductible
Do you want building replacement cost coverage?		Yes No
Do you want contents replacement cost coverage?		Yes No
Questions or Comments
If you have more than 1 residence, please fill out another form Please Note: Insurance coverage cannot be bound without a written binder from our office. Please Also Note: Many insurance carriers use information gathered from you and outside sources about your claim, credit history and home. This information allows insurance companies to determine accurately the proper price to charge. You are entitled to a free copy of the reports by contacting the appropriate consumer reporting agency within the next 60 days.
By filling out this form, you agree to the above terms.

Request for Evidence of Property Insurance