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Our Team
Insurance Solutions
Forms & Resources
Blog
Contact

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Forms & Resources

Homeowner's Insurance

By providing the following information Hidden Valley Insurance will provide you with competitive quotes from multiple insurance carriers. There is no obligation to purchase.

Policy Holder Information

Your Name*

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Date of Birth*

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Employer*

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Occupation*

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Phone*

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Email*

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Add a second name on the policy*

Yes

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Second Name*

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Date of Birth*

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Employer*

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Occupation*

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Property Information

Address of property to be insured (Note: Please complete one form per location)

Address*

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City*

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State*

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Zip Code*

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Construction Information

Year Built*

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Total Square Feet:*

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Exterior Type:*

Brick

Frame

Stucco

Siding

Other

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Other*

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Roof Type:*

Asphalt Shingles

Metal

Title

Shake

Other

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Other*

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Number of Levels*

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Basement?*

Yes

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If Yes, % Finished?*

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Was the house built over 10 years ago?*

Yes

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If Yes, provide dates of any updates to the following.

{if Roof}

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{if Electrical / Wiring}

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{if Plumbing}

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{if Heating}

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Interior Information

Total number of baths*

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Full

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¾ bath

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½ bath

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¼ bath

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Type of primary heat*

Gas

Electric

Other

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Number of woodburning stoves

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Assign values to items being insured

Dwelling (replacement cost of home):*

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Deteached Structures (shed, shop, etc)*

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Personal liability limit:

$300,000

$500,000

$1,000,000

$2,000,000

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Are you interested in an umbrella quote?*

Yes

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Desired umbrella limit

$1M

$2M

$5M

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Scheduled high value items

Jewelry

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Description

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Computer equipment

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Description

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Fine Art

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Description

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Other

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Description

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Other

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Description

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Credits

Fire extinguisher?*

Yes

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Dead Bolts?*

Yes

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Non-Smoker?*

Yes

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Alarm System?*

Yes

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{if If Yes, Type of Alarm} If Yes, Type of Alarm* {/if}

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Smoke Detectors?*

Yes

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Do neighbors have a clear view of your home?*

Yes

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Approximately how many feet to the nearest fire hydrant? *

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Approximately how many miles to the nearest fire department?*

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Claim History

Date of Claim

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Type of Claim

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Amount Paid

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Date of Claim

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Type of Claim

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Amount Paid

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Date of Claim

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Type of Claim

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Amount Paid

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Date of Claim

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Type of Claim

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Amount Paid

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Additional Risk

Is there a hot tub on the premise?*

Yes

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Is there a swimming pool on the premise?*

Yes

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{if If yes, type of pool?} If yes, type of pool?* {/if}

Indoor

Outdoor

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{if Is the pool fenced in?} Is the pool fenced in?* {/if}

Yes

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Is there a slide?

Yes

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How high is pool slide?

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Do you own any exotic pets or dogs?*

Yes

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{if If Yes, breeds?} If Yes, breeds?* {/if}

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{if Have they ever bitten anyone?} Have they ever bitten anyone?* {/if}

Yes

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Is there a trampoline on premise? *

Yes

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Are there any resident employees on premise?*

Yes

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Additional Coverage - do you need coverage for:

Earthquake*

Yes

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Flood*

Yes

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Landslide*

Yes

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Misc. Information:

Desired Deductible*

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Current Insurance Carrier*

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Current Expiration Date*

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Occupant Information

Is this home your primary residence?*

Yes

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Is the home vacant?*

Yes

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Is this home a seasonal home? *

Yes

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Is this home a rental that is occupied by a tenant?*

Yes

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Is this home occupied by the owner of the home? *

Yes

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Is this a single family dwelling or condo?*

Single Family

Condo

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Is Mortgagee Billed?*

Yes

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Mortagee Name

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Mortgagee Information

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Mortgage account number

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Thank you for providing your information to Hidden Valley Insurance. As a reminder, we will provide you with competitive quotes based on the information you've submitted. There is no obligation to purchase.

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