Fallaize Insurance Agency — Personal Lines Application

Let's start your Application

This gathers everything needed for a Personal Lines Insurance Application — applicant information, household members, and the details for any Homeowners, Automobile, and/or Umbrella coverage you're requesting. Takes about 10 minutes. Nothing here is submitted to a carrier — it just prepares the application for your agent to review.

Tip: have your prior policy declarations page, driver's license numbers, and vehicle VINs handy.

Applicant Information

Tell us about yourself and your current insurance.

Personal Information

Full Legal Name*

Date Of Birth*

Social Security Number*

Marital Status

Occupation

Employer

Contact Information

Phone Number*

Email Address*

Mailing Address

Street Address*

City*

State*

Zip*

Physical Address

Same as mailing address

Street Address

City

State

Zip

Current Insurance

Current Carrier

Policy Number

Expiration Date

Years Insured

Insurance History

Any prior policy cancellations or non-renewals?

Yes No

Any claims in the past 3–5 years?

Yes No

Household Members

List everyone else living in the household with the applicant.

Coverage Requested

Which type(s) of coverage are you applying for?

Homeowners Insurance Automobile Insurance Umbrella / Excess Liability

Please select at least one coverage type.

Homeowners — Property Details

Details about the property to be insured.

Same as mailing address

Property Street Address

City

State

Zip

Property Details

Year Built

Purchase Date

Purchase Price $

Square Footage

# Of Stories

Construction Type

Building Systems

Roof Type

Roof Age (years)

Foundation Type

HVAC Age (years)

Plumbing Age (years)

Electrical Age (years)

Fire Protection

Distance To Nearest Fire Hydrant (ft)

Distance To Fire Department (mi)

Homeowners — Risks & Usage

Protective devices, risk exposures, and how the property is used.

Protective Devices

Smoke Detectors Monitored Burglar Alarm Monitored Fire Alarm Deadbolt Locks Security System Fire Extinguisher Sprinkler System Gated Community

Pool, Trampoline & Hot Tub

Pool on premises?

Yes No

Is the pool fenced?

Yes No

Trampoline on premises?

Yes No

Hot tub / spa on premises?

Yes No

Animals

Any animals on premises?

Yes No

Breed(s)

Any bite history?

Yes No

Occupancy & Use

Occupancy Type

Is a business or daycare operated on premises?

Yes No

Location Risk Factors

Is the property near the coast, in a flood zone, or in a designated wildfire area?

Yes No

Any history of sinkhole activity at or near the property?

Yes No

Homeowners — Financial & Contents

Mortgage details and the value of personal property to be covered.

Mortgage

Lender Name

Lender Address

Loan Number

Financial History

Any bankruptcy in the past 5 years?

Yes No

Personal Property

Estimated Value Of Personal Property / Contents $

High-Value Items Needing Scheduling

Automobile — Vehicles

Add every vehicle to be insured on this policy.

Automobile — Drivers

Add every driver in the household who will operate the vehicles above.

Umbrella / Excess Liability

Details for the umbrella or excess liability policy you're requesting.

Requested Liability Limit

Underlying Homeowners Liability Limit

Underlying Auto Liability Limit

Any liability claims, lawsuits, or judgments in the past 5 years?

Yes No

Has an umbrella/excess policy ever been cancelled or declined?

Yes No

Review & Submit

Check everything below before submitting.

✅

Thanks — you're all set!

Your application data has been prepared. Choose how you'd like to send it to us: