Dwelling Package

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- Agency Name
- Contact Name
- Agency Account Nbr.
If you do not have an account with FTP complete and forward our
New Brokerage Account Questionaire

Select State in which the Risk is located:
- Applicant Name
- Location
- Zip Code
Select Occupancy:
* If BUILDER'S RISK was selected please answer the following:
** If VACANT was selected please answer the following:

Select Use:
Select Liability Limit:
Has the dwelling been updated (wiring, plumbing, heat)? YES NO
Comments (include dates):


Swimming Pool? YES NO
Is it fenced? YES NO
Are any business pursuits conducted on premises? YES NO
Describe:


Any animals? YES NO
List type & breed if a dog:


How far is the dwelling from the ocean?
Primary source of heat?
Has any company cancelled or refused coverage to applicant? YES NO
Comments:


- Previous Carrier
- Policy Number
Past Losses - None - 1 - 2 - 3 - More than 3
Explain type of Losses:






Property Limits
Dwelling
Personal Property
Additional Living Expense
Other Structures
Residence Burglary
Thank You for submitting this risk.
We will be back to you with a Quote as quick as we can.

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