Vacant Dwelling Quote (Any information is kept confidential and is only for underwriting purposes. This information will only used by Florida Direct Insurance Agency, Inc .or its' subsidiaries only)
Primary Name Email Date of Birth Social Security # Occupation
Secondary Name (if applicable) Email Date of Birth Social Security # Occupation
Home Phone # - - Work Phone # - - Cell # - -
Physical Address City County State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Mailing Address City State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY Zip
Best Time to Call 8:00am - 9:00am 9:00am - 11:00am 11:00am - 1:00pm 1:00pm - 3:00pm 3:00pm - 5:00pm 5:00pm - 8:00pm Best Place to Call Home Work Cell
Effective Date of Coverage Needed Prior Insurance Carrier Prior Policy #
Date of Expiration of Prior Coverage Years With Prior Carrier 0 1 2 3 4 5 or more Have You Ever Declared Bankruptcy Yes No
Do You Have Good Credit Yes No Have you had any homeowner or property related claims in the past five years? Yes No
If you have had any losses:
Date Details of Loss (Be brief) Amount of Claim
Year Built Value of Home Value of Contents
Deductible Requested for All other Perils $500 $1000 $2500 $5000 $10000
Windstorm Deductible 2% 3% 5% 10%
Is the Home in a Flood Zone Yes No
Is the Home in a "Wind Pool" Area Yes No
Distance to Fire Hydrant None Other 10 Ft - 100 Ft 100 Ft - 250 Ft 250 Ft - 500 Ft 500 Ft - 1000 Ft 1000 Ft - 2500 Ft 2500 Ft or Greater
Type of Construction Frame Concrete Block Solid Concrete Concrete/Styrofoam Wood Other
Square Feet of Home under Roof
Number of Bathrooms 1 1 1/2 2 2 1/2 3 3 1/2 4 4 1/2 5 5 1/2 6 6 1/2 7 or more
Central Heat and Air Yes No
Type of Roof Material Tar and Gravel Asphalt Shingle Fiberglass Shingle Concrete Tile Wood Shingle Other
Type of Roof Flat Gable Hip
Number of Fireplaces 0 1 2 3 or more
Type of Garage None 1 Carport 2 Carport 3 Carport 1 Car Garage-Attached 2 Car Garage-Attached 3 Car Garage-Attached 1 Car Garage-Detached 2 Car Garage-Detached 3 Car Garage-Detached
Is the Home on piers, stilts, pilings, or other similar structures No Yes
How many months of the year is the home owner occupied 0 months 7 months or more 7 months or less 12 months
Fire Protection None Smoke Detectors Local Fire Alarm Monitored Fire Alarm Sprinklers Local Alarm w/Sprinklers Monitored Alarm w/Sprinklers Burglar Alarm None Local Alarm Monitored Alarm
Storm Shutters No Yes - Corragated Panels Yes - Type A Shutters Yes - Type B Shutters Yes - Shutters (Not Rated)
Screen Porch Yes No If Yes, Square Footage Additional Screen Porches Square Footage
Swimming Pool No Yes What is the Square Footage of the Pool Is Swimming Pool Fenced or Caged None Caged Fenced If the Pool is Caged, What is the Square Footage
Is your home located on Open Water, Bay, Gulf, or Ocean Yes No
Is there a Mortgage on your Home Yes No
Is your Home in a Sub Division Yes No Is there a Guarded Gate Yes No
Do you own a Dog Yes No
How many months is the dwelling vacant in the course of a year
Additional Information :