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Location

Date Policies Should Start*

MM slash DD slash YYYY

Types of Insurance*

Selecting Home includes primary homes, secondary homes, or rental property.

Home

Flood

Auto

Disability

Life

Builders Risk

Marine

For a Builders Risk policy Click here to start Application.

How were you referred to us?

Primary Applicant

Name*

First Last

Date of Birth*

Month

Day

Year

Email*

Phone*

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By checking this box, you consent to receive text messages from Fountainhead Insurance at the mobile number provided regarding your insurance inquiries, quotes, and policy updates and promotional/marketing messages. Consent is not a condition of purchase. Message and data rates may apply. Message frequency varies. Reply HELP for help or STOP to cancel. View our Privacy Policy and Terms of Service

Drivers License Number

Drivers License State

Gender*

Marital Status*

Occupation*

Employer

Is there a Co-Applicant?

Yes

Co-Applicant

Co-Insured Name*

First Last

Co-Insured Date of Birth*

Month

Day

Year

Co-Insured Email*

Co-Insured Phone*

Co-Insured Drivers License Number

Co-Insured Drivers License State

Co-Insured Occupation*

Co-Insured Employer

Current Address

Current Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address*

Same as Current Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Property Information

Type of Home

Property Address*

Same as Current Physical Address

Street Address Address Line 2 City State ZIP Code

Primary Use For Home

Gross annual rental revenue*

Property is rented*

Long Term

Short Term

How long is construction expected to take?*

When did construction begin?*

Did you have prior builders risk insurance?*

Yes

How many years’ experience does the Contractor have?

Is property titled in a name Other Than your personal name(s)?

Example: Trust, LLC, Corporation, Partnership, etc.

Yes

Name on Title of Property*

Is this a New Purchase?*

Yes

Name of Current Insurance Company

Current Policy Expiration Date

MM slash DD slash YYYY

Is there a Mortgage on the property?*

Yes

Lender Name

Loan Number

Additional Property Coverage Interests

Flood

Have Animals?

Yes

Type of animal and how many?

Let's enter your property information by completing each section below.

Home Information

Is home newly built?

Yes

Home currently under construction?*

Yes

Is this a prefabricated home?*

Yes

Building Location

Year Built*

Building Square Feet*

Square Feet (Porches or Decks)*

# of Stories

# of Bedrooms

# of Bathrooms

Security System

Is there a swimming pool?*

Yes

Is pool fenced?*

Yes

Construction Information

Exterior Construction Type

Exterior Cladding (exterior surface of dwelling)

Hurricane Resistant Glass?*

Yes

Does glass meet Miami Dade County test standard?*

Yes

Unknown

Hurricane Shutters?*

Yes, Fully

Yes, Partially

Shutter Type(s)*

Hinged Wood

Steel Panels

Roll Down

Accordion

Pre-cut Plywood

Armor Screen

Aluminum Miami Louvers

Other

Please explain how exterior openings will be protected in the event of a Hurricane*

Any iron grill work?

Yes

Roof Information

Roof Material

Roof Shape

Roof Structure

Roof Anchor System

Roof Cover Fastening

Interval Between Fastenings

Roof Overhang

Laths or Purlins

If over 2”, specify exact measurement of overhang?

If more than 24” apart, specify distance apart?

Property updates

Has there been any updates to the Roof, Plumbing or Electrical?

Yes

Roof Update Year

Roof Update Completion

Full

Partial

Plumbing Update Year

Plumbing Update Completion

Full

Partial

Electrical Update Year

Electrical Update Completion

Full

Partial

Have any alterations or improvements included windstorm damage protection?*

Yes

Explain windstorm damage protection improvements*

Solar Panels?

Yes

Number of Solar Panels

Value of Solar Panels

Solar Panels are

Attached to dwelling

Standalone

Premises has available

Cistern Water

City Water

Swimming Pool

Additional Information

Fire Extinguishers?*

Yes

Number of Fire Extinguishers

Smoke detectors?*

Yes

Number of smoke detectors

Are smoke detectors hard-wired?

Yes

Miles to nearest fire department

Leave blank if unknown.

Will the property every be unoccupied for more than 30 consecutive days?*

Yes

Is the property in a good state of repair and will be so maintained?*

Yes

Has the property been free from flooding during the last 10 years*

Yes

Unknown

Is property adjacent to any body of water such as a sea, lake, or canal?*

Yes

Unknown

Has the property sustained any loss, damage, or liability during the past 5 years?*

Yes

Unknown

Description and amount of property loss, damage, or liability*

Have you ever been convicted of any offense other than driving offenses?*

Yes

Detached Structures

Does home have any detached structures?

Yes

What types of detached structures?

Fence

Guest House

Pool House

Shed

Deck

Other

Other type of detached structure

Coverage Limits

Enter your desired coverage limits for your property. If you don't know you may skip this section. We will discuss your options with you.

Dwelling Coverage

Other Structures Coverage

Personal Property Coverage

Los of Use Coverage

Liability Coverage

Deductible

Photos

If New Purchase: Upload copy of appraisal

If Currently Owned: Upload most recent appraisal and current pictures of property. Photos needed: Exterior, all 4 sides, and interior picture of each room.

Photos of Home or Appraisal

If you would like to attach any pictures of your home inside and/or outside, please do so here.

Drop files here or

Max. file size: 1 MB.

Property Underwriting Information

Has any coverage been declined, cancelled, or non-renewed during the last 3 years?*

Yes

Please explain

Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the past 5 years?*

Yes

Please explain and provides dates

Has the applicant had a judgement or lien during the past 5 years?*

Yes

Please explain and provide dates

Any other residences, not listed on any application owned, occupied, or rented?*

Yes

Any business conducted on premises?*

Yes

Type(s) of business conducted

Farming

Telecommuter

Day Care

Home Office / Business

Other

Any residence employees?*

Yes

Number Full Time Employees

Number Part Time Employees

Any flooding, brush, forest fire, or landslide hazard?*

Yes

Please explain

Is the property situated on more than one acre?*

Yes

Number of Acres

Any uncorrected fire or building code violations?*

Yes

Please explain

Is the dwelling/home for sale?*

Yes

Is the property within 300 feet of a commercial or non-residential property?*

Yes

Please explain

Is there a trampoline on the premises?*

Yes

Was the structure originally built for other than a private residence and then converted?*

Yes

Please explain

Any lead paint?*

Yes

If a fuel tank is on premises, has other insurance been obtained for the tank?*

Yes

Not Applicable

Is the residence in a gated community?*

Yes

Is there an approved carbon monoxide alarm in operating condition within the mandated number of feet of every room used for sleeping purposes?*

Yes

Is the named insured the owner of the property?*

Yes

What is the owner's name?

Is there a manager on the premises?*

Yes

Is there a security attendant?*

Yes

Is the building entrance locked?*

Yes

Vehicles and Drivers Information

Vehicles

VIN	Year	Make	Model	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Drivers

If you have additional drivers in your household, please enter their information below.

Driver Name	Date of Birth	Gender	Drivers License #	Drivers License State	Actions

There are no Drivers.

Maximum number of drivers reached.

Boat Information

Serial Number*

Year*

Make*

Model*

Hull ID Number

Boat Registration Number

This is the ID number assigned to your boat by the state.

Hull Material

Number of Motors

Propulsion Type

Max Horsepower

Max Speed

Current Value

Fishing Equipment Coverage

Insure the Trailer?

Yes

Life Insurance

Primary Applicant: Amount of Coverage*

Primary Applicant: Duration*

Does Primary Applicant Have a Current Life Policy?

Yes

Primary Applicant: Height

Feet and Inches

Primary Applicant: Weight

Pounds (lbs)

Does Co-Insured Want Life Insurance?

Yes

Co-Insured: Amount of Coverage*

Co-Insured: Duration*

Does Co-Insured Have a Current Life Policy?

Yes

Co-Insured: Height

Feet and Inches

Co-Insured: Weight

Pounds (lbs)

Wrapping Up

Any Claims in the Past Three (3) Years?*

Yes

Please describe past claims*

Additional Comments

Attach Documents, Images, or Other Files

Drop files here or

Max. file size: 12 MB.

Would you like a quote from a specific agent?

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

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Name

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Property Insurance

Flood Insurance

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Primary Applicant

Co-Applicant

Current Address

Property Information

Home Information

Construction Information

Roof Information

Property updates

Additional Information

Detached Structures

Coverage Limits

Photos

Property Underwriting Information

Vehicles and Drivers Information

Boat Information

Life Insurance

Wrapping Up

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