1 Of 5
Personal Lines Application
Agent Name
Phone
Agency Code
Email
What would you like to quote?
Homeowners
Yes
No
Collections
Yes
No
Umbrella
Yes
No
Auto
Yes
No
General Information
Street
County
City
State
Zip
Insured Name
Spouse Name
Insured Phone
Occupation
Occupation
Email
DOB
DOB
Homeowners
Current Carrier
Effective Date
Target Premium
Has the current policy been cancelled, non-renewed or is location for sale?
Yes
No
If Yes, Please Explain
Is this a new purchase?
Yes
No
If yes, prior address:
Is this the same location as listed above?
Yes
No
Street
County
City
State
Zip
Occupancy
Primary
Secondary
Secondary w/ rental exposure
Rented to Others
Dwelling Form
DP1
DP3
HO3
HO4
HO5
HO6
Rentals
Rental Days Per Year
Rental Purchase Price
Rental Policy Number
Rental Expiration Date
Date Of Purchase
Rental Prior Carrier
LLC/Trust
Is home owned in an LLC or trust?
Yes
No
Provide Full Name of LLC/Trust
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Personal Lines Application
Construction Type
Frame
Brick
Stucco
EIFS
Brick Veneer
Concrete Block
Year Built
Roof Reno Year
Plumbing Reno Year
Roof Covering
Asphalt Shingle
Clay Tile
Concrete Tile
Metal
Slate
Rubber Membrane
Wood Shingle
Number of Stories
Number of Mortgages
Secured Community
Single Entry
24-hour Patrol
24-hour Manned Gate
Passkey
None
Builder Name
Losses within last 5 years
Yes
No
Basement
No
Finished
Unfinished
Finished/Unfinished
Architectural Style
Colonial
Bungalow
Pueblo
Modern
Victorian
Contemporary
Ranch
Mediterranean
Spanish
HVAC Reno Year
Electric Reno Year
Roof Shape
Custom Complex
Flat
Gable
Hip
Mansard
Other
Square Footage
Pool/Hot Tub
Yes
No
Pool Features
Unfenced
Fence to Code (>4ft High)
Locking Gate
Locking Cover
Slide
Screen Enclosure
Diving Board
Losses
Date of Loss
Type of Loss
Details
Amount Paid
Open/Closed
Yes
No
Yes
No
Yes
No
Coverage Amounts
Dwelling
Other Structures
Personal Property
Personal Liability
Deductible Request
$1,000
$2,500
$5,000
$7,500 (Chubb Only)
$10,000
$25,000
$50,000
$100,000
Hurricane/Wind Ded
N/A
2%
3%
5%
10%
Homeowner Credits (check all that apply)
Central Station Fire Alarm
Gated Community
Fire Sprinkler System
Water Shutoff With Alarm
Central Station Burglar Alarm
Perimeter Gate
Signal Continuity
Water Shutoff Without Alarm
Low Temperature Sensor
Lightning Protection
Backup Generator Protection
Water Leak Detection
Fire Protection
Within 5 Miles of Fire Dept.
Alternative (Year-Round) Water Source
Within 1000 ft of Fire Hydrant
PC Class
Additional Comments
3 Of 5
Personal Lines Application
Wind Mitigation Credits
Yes
No
Reinforced Concrete Roof Deck
Yes
No
Roof Covering
FBC
Non-FBC
Reinforced Concrete Roof Deck
Roof Deck Attachment
Level A - 6d - 6"12"
Level B - 8d - 6"/12"
Level C - 8d - 6"/6"
Reinforced Concrete Roof Deck
Roof Wall Attachment Features
Clips
Double Wraps
Single Wraps
Toenails
Reinforced Concrete Roof Deck
SWR
Yes
No
Opening Protection
Hurricane Impact
Basic Impact
None
4 Of 5
Personal Lines Application
Collections
Fill any applicable columns.
Jewelry
Fine Arts
Fur
Silver
Wine
Guns
Collections
Other
Itemized
No. of Items
Blanket
Umbrella
Fill any applicable fields.
Prior Carrier
Target Premium
Umbrella Limit
EPLI
Yes
No
Not For Profit D&O
Yes
No
Drivers
Watercrafts
Limits
Desired Effective Date
Excess UM/UIM Limit
How Many Employees
Homes
Autos
Youthful Drivers
Auto
Prior Carrier
Target Premium
Limits
Desired Effective Date
Drivers
Fill one row for each driver.
Driver Name
Date of Birth
License Number
State
Usage
Vehicles
Fill one row for each vehicle.
Year
Make/Model
Value of Vehicle
VIN#
State
Assigned To
Combined Single Limit
$100,000
$300,000
$500,000
$1,000,000
Property Damage
$50,000
$100,000
$300,000
$500,000
$1,000,000
Collision Deductible
$100
$200
$300
$500
$1,000
$2,500
$5,000
$10,000
Split Limits
50/100
100/300
250/500
500/500
1,000,000/1,000,000
Comp Deductible
$100
$200
$300
$500
$1,000
$2,500
$5,000
$10,000
Show MVR/CLUE?
Yes
No
MVR/CLUE:
Type
Date
Driver
Details
5 Of 5
Personal Lines Application
Additional Comments
Submit any additional documents.
Document types:
Word Or
PDF
Complete
Halcyon Underwriters has received your application. Thank you!