Property Information Disclosure Property Information Disclosure Property disclosure sheet for new business. "*" indicates required fields Name* First Last Birth Date* Month Day Year Spouse's Name First Last Birth Date Month Day Year Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Address of the property being insured* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of your Mortgage Company if you have oneWe need this information to send your mortgage company proof of replacement coverage and include their specific legal requirements. Loan numberWe need the loan number because your lender uses it to match the documents to your account. Is your property insurance paid through an escrow account? Yes No How do you hold title to this property?Please list the legal name of any LLC, LP, or trust or individuals on the title in this line. How are you using this property:*If you use the property for Air B&B, seasonal rental, VRBO or any business use, please let us know so we can advise you appropriately.as your primary residenceas a second homeas a rental propertycurrently vacant / under renovation / for saleIf this is a rental property, do you use a property manager? Have you had any property insurance claims in the past 5 years* Yes No Are there any dogs matching the description on the property?*Pitbulls, Doberman Pinschers, Akita, Chow, Rottweiler, German Shepard, Wolf, Wolf Hybrid, any mix containing these breeds or any dog with a previous bite history are prohibited by most insurance companies. Yes No Does the property have a pool?* YES No Is there a trampoline on the property?* YES NO When would you like your new policy to start?*Waiting for your renewal date is not necessary, we provide a pre-written cancelation notice to obtain a refund of the unearned premiumfrom your current insurance carrier. Month Day Year I acknowledge reading the disclaimer*By submitting this form you are granting your permission for Rightway Insurance LLC to bind coverage based on a previously provided quote. Failure to accurately answer the questions may result in the denial or cancelation of coverage by the insurance carrier. The insurance carrier reserves the right to verify that the property meets their underwriting guidelines. Coverage is not effective until it has been approved by underwriting.
