KMRD Homeowners/Dwelling Application

Homeowners Insurance Application

* Required

Name: *

S.S. #: *

D.O.B.: * +

Single or Married: *

Occupation & Education Level: *

Email: *

Phone Number: *

Property Location:

Street: *

City: *

County: *

State: *

Zip: *

Mailing Address (if different than above):

Street:

City:

State:

Zip:

Previous Address if Less Than 3 Years:

Street:

City:

State:

Zip:

Property Limits:

Upload Current Policy if Available: 🛈

Coverage A - Dwelling / A&A:

Coverage B - Other Structures:

Coverage C - Personal Property:

Coverage D - Loss of Use:

Liability Limits:

Coverage E - Personal Liability:

Coverage F - Medical Payments:

Deductible:

Additional Coverage(s)

Water/Sewer Backup

Special Coverage Personal Property

ID Fraud

Dwelling Information

1. Year Built:

Year:

Date Purchased:

2. Type of Kitchen:

3. Date of Updates:

Heating: +

Electrical: +

Knob & Tub Wiring: +

Plumbing: +

Roof Age: +

4. Constuction Type:

5. Exterior Wall Materials:

Feet to Hydrant:

Miles to Fire Dept:

6. Style of Home

7. Roof Type

Roof Materials:

8. Number of Families:

9. Row or Town home?

End or Center Unit?

How many units in row?

10. Is there an association?

11. Square Footage:

12. Number of baths:

Builder's Grade Full:

Builder's Grade Half:

Custom Full:

Custom Half:

13. Basement:

Square Footage:

14. Attic:

15. Number of Fireplaces:

Number of Wood Burning Stoves:

16. Primary Heat Souce:

Underground Fuel Tank?:

17. Central Air?

18. Garage Type:

Number of Cars: 🛈

19. Deck or Patio?

Deck/Patio Square Feet:

Deck/ Patio Materials:

20. Other structures on premises?

21. Are there any business property/pursuits?

22. Type of Pool:

Fenced?:

Diving Board/Slide:

23. Trampoline on premises?:

24. Animals or Exotic Pets?:

Breed/Type/Bite History/Training:

25. Protective Devices/Alarms:

Protective Devices:

Fire Extinguisher

Deadbolt Locks

Smoke Detectors

Sprinkler System

Alarms:

Central Burglar

Central Fire

Local Burglar

Local Fire

26. Current Carrier:

Expiration Date: +

Policy #:

Loss History

Date: +

Type:

Description:

Amount:

Additional Insured

Name of Mortgagee:

Loan #:

Mortgagee Billed?:

Street:

City:

State:

Zip:

Thank you for utilizing this system. You should recieve confirmation of your request via email. A KMRD representative will reach out to you with questions if we have them. If you do not hear from us, feel free to call at 866-957-KMRD (5673) or contactus@kmrdpartners.com

This form is for communication purposes only. This form does not bind coverage