Condo Owners Quote  (Any information is kept confidential and is only for underwriting purposes for condominium associations, condoowners, apartments, apt, vacant, occupied.. This information will only used by Florida Direct Insurance Agency, Inc .or its' subsidiaries only)

Primary Name for Owner  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 Condo Owners 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

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Date     Details of Loss (Be brief)       Amount of Claim

Year Built  Value of attached emenities (from drywall out, anything attached permanently to the wall)      Value of Contents          

Deductible Requested for All other Perils $500 $1000 $2500 $5000 $10000                   

Windstorm Deductible 2% 3% 5% 10%

Association Assessments $1000 $2000 $3000 $4000 $5000

Is the condo in a Flood Zone Yes No            

Is the condo 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 of Condominium Frame Concrete Block Solid Concrete Concrete/Styrofoam Wood Other   

Square Feet of Home of the unit  

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  

Number of Fireplaces 0 1 2 3 or more   

How many months of the year is the Condo 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     

Is your Condo located on Open Water, Bay, Gulf, or Ocean Yes No  

Is there a Mortgage on your Condo Yes No  

Name of the Condominium Association              Is there a Guarded Gate Yes No  

Do you own a Dog Yes No

Is there a German Shepherd, Rottweiler, Pit Bull, Mastiff, Rhodesian Ridgeback, Doberman Pincher, Akita, or Kerr on the premisis Yes No

Additional Information :