Homeowners & Flood
Quote Sheet
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Policy Type
Select…
HO
DP
Condo
Renters
MH
Mono Flood
Occupancy
Select…
Primary
Secondary
Rental – Long-term
Rental – Short-term
Flood Quote?
Yes
No
Notes
1
File & Referral Info
Agent
Select…
Becca
Emily
GA/Danny
Jennie
Mallory
Rob
Sam
Referred By
Company
New Purchase?
Yes
No
Mortgagee Clause
Mortgagee Name
Street Address
City
State
--
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Loan Number
2
Insured Information
Primary Insured
First Name
Middle Name
Last Name
Suffix
Jr
Sr
II
III
IV
Date of Birth
Social Security #
Marital Status
Select…
Married
Single
Divorced
Widowed
Occupation
Phone
Email
+ Add Co-Insured
3
Subject Property Address
Street Address
City
State
--
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
County
4
Other Addresses
Mailing Address
Same as Subject Property
Street Address
City
State
--
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Previous / Current Address
Street Address
City
State
--
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
5
Property Details
Year Built
# Stories
Sq Footage
Beds
Full Baths
Half Baths
Construction Type
Select…
Brick
Hardi
Vinyl
Stone
Stucco
Tabby
Wood
Cinderblock
Foundation Type
Select…
Slab
Crawlspace
Raised Slab
Enclosure
Piers
Basement
Garage Type
Select…
None
Attached / Built-in
Detached
Carport
# of Cars
Heat / Air Type
Select…
Central Heat & Air
Central Heat / Window AC
Window Units Only
Baseboard
Radiator
Mini-Split
None
Laundry Floor
Renovations & Systems
Roof Year
Roof Shape
Select…
Gable
Hip
Flat
Gambrel
Mansard
Other
Roof Type
Select…
Architectural
3-Tab
Metal
Tile
Wood Shake
Flat/TPO
Other
Scope
Select…
Full
Partial
Elec Year
Scope
Select…
Full
Partial
HVAC Year
Scope
Select…
Full
Partial
Plumb Year
Scope
Select…
Full
Partial
Water Htr
Tankless?
Yes
No
Safety & Features
Fire Alarm
Select…
None
Local
Central Station
Direct
Smart
Burglar Alarm
Select…
None
Local
Central Station
Direct
Smart
Sprinklered?
Yes
No
Gated Community?
Yes
No
# Fireplaces
Pool?
Yes
No
Trampoline?
Yes
No
6
Desired Coverage Amounts
Dwelling (Cov A)
$
Other Structures (Cov B)
$
Contents (Cov C)
$
Loss of Use (Cov D)
$
Liability (Cov E)
$
▾
Medical Payments (Cov F)
$
▾
AOP Deductible
$
%
Hurricane Deductible
HU
W/H
$
%
7
Underwriting Questions
Bankruptcy, Foreclosure, or Felony (last 5 years)?
Yes
No
Dogs?
Yes
No
Any Claims?
Yes
No
8
Location & Rating Info
Protection Class
Territory Code
Miles to Fire Dept
More than 5 miles
Feet to Fire Hydrant
More than 1000 ft
Miles to Coast
Barrier Island?
Yes
9
Quoted Through / Premium
Check Eligibility
Needs: State, Year Built, Roof Year, Policy Type
1
Carrier
Annual Premium
$
+ Add Quote
Robinson & Associates — Homeowners & Flood Quote Sheet
v3.1
© 2026 Reardon Insurance, LLC. All rights reserved.
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