Black Insurance Agency LLC

Black Insurance Agency LLC

If you do not know the answers to any questions, that is fine. 😉

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If you do not know the answers to any questions, that is fine. 😉
Type of Insurance*
Auto Insurance
Primary Insured Name
First Last
Home Phone
Home Address
Street Address Address Line 2 City State ZIP Code
Work Number
Email Address*
Garaging Address
Street Address Address Line 2 City State ZIP Code
Occupation
Own or Rent your home?
Date of Birth
MM slash DD slash YYYY
Drivers License Number
State
Spouse Name
Date of Birth of Spouse
MM slash DD slash YYYY
Current Auto Insurance Company
Renewal Date
MM slash DD slash YYYY
6 Month or 12 Month Term?*
- 6 Month
- 12 Month
Any Lapse in Coverage?
Other Household Members?
Any accidents in last 3 years?
- Yes
- No
Any accidents in last 6 years?
- Yes
- No
Any minor moving violations (tickets) in last 3 years?
- Yes
- No
Any moving violations in last 6 years?
- Yes
- No
Any major violations (2 points) in last 3 years?
- Yes
- No
Any major violations in last 6 years?
- Yes
- No
Please explain any Yes answers below.
Vehicles
Year Make Model
Odometer
Reading
Primary Driver Used for Business
- Yes
- No
UPLOAD DOCUMENTS HERE
Drop files here or

Max. file size: 512 MB, Max. files: 10.
*Copy of Drivers License
* Copy of a Dec page of your current insurance
HomeOwners Insurance
Primary Insured Name
First Last
Home Phone
Address to be Insured
Street Address Address Line 2 City State ZIP Code
Work Phone
Mobile Phone
Mailing Address
Street Address Address Line 2 City State ZIP Code
Email Address
Occupation
Date of Birth
MM slash DD slash YYYY
Current Home Insurance Company
Renewal/Effective Date
MM slash DD slash YYYY
Has property insurance been cancelled, declined or non-renewed in the last 5 years?
- Yes
- No
Townhouse or Condo?
- Townhouse
- Condo
- No, Other
Is it a center unit or end unit?
- Center Unit
- End Unit
Does your homeowners association (HOA) cover/insure the structure?
- Yes
- No
How many units attached in the same building
Type of Home
Dwelling Usage (Primary, Secondary/Vacation, Rental)
Is the home under construction?
- Yes
- No
Is there a swimming pool on the premises?
- Yes
- No
is the pool fenced?
- Yes
- No
Are there dogs on the premises?
- Yes
- No
How many?
Limits
- Inside city limits
- Outside city limits
Feet from hydrant
Distance from Fire Station
Distance to Brush
Distance to Tidal Water
Exterior Walls
Roof Type
If tile, Spanish, or concrete)
Roof Age (in years)
Year Built
Square Feet
Number of Stories
Purchase Date
MM slash DD slash YYYY
Heating Type
- Gas
- Electric
- Other
Foundation: Slab or Crawl space
Home Bolted to the foundation?
- Yes
- No
If renovations to plumbing, heating, and/or electrical, please provide year renovation(s) were completed:
Any Smokers in household?
- Yes
- No
Auto insurance with
Dead Bolt Locks on ALL doors leading to Exterior?
- Yes
- No
Fire Extinguisher?
- Yes
- No
Smoke Detectors (Alarms)
- Yes
- No
Burglar Alarm?
- Yes
- No
Central Monitoring?
- Yes
- No
Does house have a seismic/automatic gas/propane shutoff valve?
- Yes
- No
Visible to Neighbor?
- Yes
- No
Gated community?
- Yes
- No
Gated community 24 hour patrol service?
- Yes
- No
UPLOAD DOCUMENTS HERE
Drop files here or

Max. file size: 512 MB.
*Copy of Drivers License
* Copy of a Dec page of your current insurance
Business Insurance
Are you currently insured?
- Yes
- No
If no, have you ever been insured?
- Yes
- No
Corporate Name*
DBA Name*
Business Phone
Type of Establishment
Address
Street Address Address Line 2 City State ZIP Code
Mobile Phone
Contact Name*
First Last
E-mail Address
How did you hear about us?
Best Time to Call

: Hours

Minutes
Dance Floor?
- Yes
- No
Liquor Sales
Other Sales
Coverage Desired
General Liability
Liquor Liability
Property Coverages
Building
Contents
Business Interruption
Current Carrier
Other Info
UPLOAD DOCUMENTS HERE
Drop files here or

Max. file size: 512 MB.

Black Insurance Agency LLC

Auto Insurance

HomeOwners Insurance

Business Insurance