High Wildfire Danger Home Insurance Quote - Premier Mountain Insurance

If you have any questions while filling out this application, please call 303-922-1002, extension 1003

Has your home insurance been declined or non renewed due to high wildfire risk? Have you been strugging to find an insurance carrier to accept your home due to wildfire risk? If so, complete this form for us to begin working on your home insurance.

- Step 1 of 2

Name *

First

Last

Date of Birth *

Is the home you wish to insure titled in your personal name? *

Is there a co-applicant? (spouse, co-owner, etc) *

Co Applicant Name *

First

Last

Date of Birth of Co Applicant *

Entity Name home is titled to:

What is your occupation? (State Nature of business if self-employed) *

Email Address *

Phone Number *

Within 60 days of starting this policy the insurance carrier will conduct an on-site inspection to validate information about your home. Will you be the inspection contact? *

Normally you are the inspection contact if this is an owner-occupied home. Secondary homes or rental properties may utilize a property manager to meet the inspector.

Inspection Contact Name *

First

Last

Inspection Contact Phone *

Inspection Contact Email *

Address of home you wish to insure *

Address Line 1

City

State / Province / Region

Postal Code

Is this home new construction? *

Have you lived at this address for at least three years? *

Prior Address *

Address Line 1

City

State / Province / Region

Postal Code

Is there a different mailing address? *

Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Is this a new purchase? *

What is the anticipated closing date (purchase date)? *

What was the purchase date of the home? *

Has there been a lapse in coverage? *

When did your last policy expire? *

Who is the current insurance carrier?

Expiration Date

What was the reason for the lapse in coverage? *

Is the current policy being nonrenewed? *

Is the current policy being cancelled? *

Reason for non renewal or cancellation: *

If you already own this home, is it listed for sale, or do you plan to sell it in the next 12 months? *

Occupancy: *

Owner Occupied
Seasonal / Secondary Residence
Rental (Long Term)
Short Term Rental
Vacant
Vacant Renovation

Are there tenants currently occupying the property? *

Number of Months Rented:

Minimum Stay:

Number of Months Vacant:

Is building undergoing renovation or construction? *

Describe the renovations *

Number of Families: *

Is there a fire hydrant within 1,000 feet from the dwelling? *

Is the responding fire department within 20 minutes year-round of the property? If no, how far away is it? *

Protective Device Types

Central Smoke Alarm
Central Temperature Alarm
Central Burglar Alarm
Local Smoke Alarm
Local Temperature Alarm
Local Burglar Alarm

A central system means that your alarms automatically call a centrally monitored call center.

Additional Protective Questions:

Deadbolts
Fire Extinguisher
Home is visible to neighbors
Interior Sprinklers, Fully Sprinklered
Interior Sprinklers, Partially Sprinklered

Is the property is accessible by emergency vehicle year-round? *

What year was the house built? *

What is the total above ground livable square feet (not including basements, garages or porches)? *

Has the roof ever been replaced? If so, what year? Was it the entire roof or partial replacement?

Has the wiring ever been replaced? If so, what year? Was it the whole home or part?

Has the furnace or heating system ever been replaced? If so, what year? was it the whole system or partial?

Has the plumbing ever been replaced? If so, what year? Was it the whole system or part?

Roof Type:

Concrete / Clay Tile
Roll / Membrane
Asphalt Shingle
Metal
Wood Shake
Other

Roof Type:

Construction Type: *

Frame
Log - Milled
Masonry
Log - Hand Hewn
Dome
Manufactured / Mobile
Other

Construction Type:

Building Type:

Single Family Detached
Condo (interior coverage only)
Townhouse (including duplex)
Other

Building Type:

Foundation Type:

Basement
Post / Pier
Crawlspace
None
Slab
Other

Foundation Type:

Is the basement finished? *

Fully finished or paritial? If partial, what percentage?

Does the house have pre 1998 EIFS siding (this is a specific type of synthetic stucco)? *

Any current or prior mold issues at this property? *

Is there any knob & tube or aluminum wiring and/or less than 100 amps? *

Provide additional details to the yes response regarding the wiring type.

Do you have plans to update the wiring within 30 days? *

Does the electrical system have Federal Pacific , Stab - Lok, Zinsco, Sylvania, or Challenger brand breaker panels? *

Do you have plans to update the electrical panel in the next 30 days? *

Is the plumbing supply line or exit / waste drain made of cast iron, galvanized, lead, or polybutylene materials? *

Do you have plans to update the plumbing in the next 30 days? *

Does the home have any existing damage (inside or out)? *

Describe the damage:

Primary Heat Source *

Natural Gas
Propane Gas
Woodburning Stove
Electric
Space Heater
Other

Primary Heat Source:

Is the primary heat source controlled by a central unit (such as a thermostat)? *

Secondary Heat Source *

Natural Gas
Propane Gas
Woodburning Stove
Electric
Space Heater
Other
None

Secondary Heat Source:

Is solid fuel appliance professionally installed? *

Does solid fuel appliance meet manufacturers installation guidelines? *

Is solid fuel appliance UL-listed? *

Is solid fuel appliance regularly maintained? *

Does the solid fuel appliance share flue with another furnace or appliance? *

If you would like to request a specific dwelling limit amount (projected cost to rebuild the main structure), you can put it here. If you are not sure, you can leave this blank. We will run a reconstruction cost estimate to ensure the coverage is adequate.

Are there any detached structures on the property (shed, barn, garage, gazebo, fence, etc.)? *

Describe the detached structures: *

How much do you believe it would cost to replace the detached structures? *

How much would it cost to replace all of your personal property in this home? *

If your home were to burn down entirely, how much would you want your carrier to pay out to cover living expenses while your home is rebuilt? If you have a secondary home where you can stay, you may exclude this coverage. The savings from exclusion could range from $600 to $1,300 per year, depending on the limit you choose. Typical amounts range from $80,000 to $140,000. *

All Peril Deductible Amount *

Have you had any bankruptcies, foreclosures, or repossessions in the last 5 years? *

Have you been indited for or convicted of fraud, bribery, or arson? *

Is the house used for student housing, group homes, daycare, or adult family care? *

Is the home on the historic registry? *

Is the home within 300 feet of a commercial property? *

What type of business?

Was the house built for other than private residence and converted? *

Any businesses on the premises? *

Describe the business on premises:

Is there a swimming pool?

Additional Pool Questions *

Fence (Min 4 feet)
Diving Board
Slide > 5 feet
Locking Gate

Is there a hot tub / spa on the premises? *

Is the hot tub / spa secured with a lockable cover? *

Is there a trampoline on the property? *

Does the trampoline have a safety net? *

Will there be a dog on the premises? *

How many dogs and what are the breeds?

Any prior bite history?

Are there any domestic, farm, or exotic animals on the premises?

Is property situated on more than five acres? *

Describe the land use:

Any hunting, logging, new construction, or farming on the land? *

Is there a barn on the property? *

Is the barn used for storing animals, hay, or feed?

Does the barn have stalls? *

Any losses, whether or not paid by insurance, in the last five years at this, or any other location? *

Please provide date of loss, type of claim, description, amount paid and whether or not the claim is closed for each claim.

Will there be a mortgage? *

Is there a mortgage? *

Is the insurance paid through your mortgage escrow account? *

How did you hear about our agency? *