Homeowners Insurance – Orr & Associates Insurance Services

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Agent

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Agent Phone

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Agent Email

Name*

First Last

Please enter the name of the homeowner.

Phone*

Email*

Address*

Street Address City State ZIP Code

Please enter the address of the property to be insured.

Home Description

Number of Bedrooms

Number of Bathrooms

Number of Stories

Square Footage

If you don't know the square footage, please enter 0 and we can look it up for you.

Year Built

If you don't know the year built, please enter 0000 and we can look it up for you.

Is the home owner-occupied, rented, or vacant?

Owner-occupied

Rented

Vacant

Primary Residence or Secondary Residence?

Primary Residence

Secondary Residence

Home Purchase Date

Do you run a business from home?

Yes

Do you have any tenants or boarders?

Yes

Homeowner's Social Security Number

Homeowner's Date of Birth

Homeowner's Marital Status

Household Members (including dependents away at school or military)

Is there a mortgage on the property?

Yes

Is the home currently insured?

Yes

Safety Features

Current Insurance Carrier

Policy #

Expiration Date

Coverage Amount

Deductible

Years of Uninterrupted Coverage

Have you had any homeowners insurance losses/claims in the past 5 years?

Yes

Are you aware of any circumstances, incidents, or conditions that may potentially give rise to a claim under this homeowners insurance policy?

Yes

Mortgage Company

Providing the mortgage company information upfront streamlines the certificate of insurance processing time.

Mortgage Company Address

Street Address City State ZIP Code

Providing the mortgage company information upfront streamlines the certificate of insurance processing time.

Loan Number

Providing the mortgage company information upfront streamlines the certificate of insurance processing time.

Loan Amount

Providing the mortgage company information upfront streamlines the certificate of insurance processing time.

Policy Effective Date

Building Limit

Please enter the value of the building only. Do not include the cost of land or building contents.

Personal Property Limit

Please enter the value of personal property in the building including furniture, clothing, electronics, appliances, books, art, musical instruments, sports equipment, bicycles, tools, cookware, bedding, linens, collectibles, small appliances, home décor items, garden equipment, personal grooming devices, outdoor furniture, luggage, kitchenware, and toys.

Additional Coverage Options

Jewelry and Furs Limit

Enter an amount between $1,500 and $7,500.

Money, Coins

Enter an amounmt between $200 and $1,000

Securities, Stamps

Enter an amount between $1,500 and $3,000.

Silverware

Enter an amount between $2,500 and $10,000.

Firearms

Enter an amount between $2,500 and $6,500.

Electronic Apparatus in/upon Vehicle

Enter an amount between $1,500 and $6,000

Roof Type*

Year Roof Installed

If you don't know the year the roof was installed, please enter 0000 and we can look it up for you.

Foundation Type

Construction Type

Cooling Type

Heating Type

Garage

Date of Most Recent Renovation

If you don't know the date of most recent renovation, please enter 01/01/0000 and we can look it up for you.

	Yes	No
Burglar Alarm System
Fire Alarm System
Smoke Detectors
Carbon Monoxide Detectors
Fire Extinguishers
Deadbolt Locks
Gated Community
Security Cameras

	Yes	No
Earthquake
Flood
Jewelry and Furs
Money, Coins
Securities, Stamps
Silverware
Firearms
Electronic Apparatus in/upon Vehicle
Tapes, Records, Discs, or Other Media in/upon Vehicle
Home Computers

Homeowners Insurance Application