Please complete the following and press submit or call 800-396-6226 x107 for an instant phone quote

Agent Information:
Commonwealth Underwriters Agent Code:	*Note: this field is optional* Forgot Code?
Agency Name:
Agent Name:
Agent Phone:
Agent Email:	(A copy of the quote will be sent to this address)

Insured Information:
Insured Name:
Insured Email:	(will only be used to communicate regarding this account)
Insured Phone Number:
Occupation:
Employer:
Date of Birth:	//
Is there an additional resident or spouse?
Additional Resident's Name:
Additional Resident's Occupation:
Additional Resident's Employer:
Additional Resident's Date of Birth:	//
Mailing Address:
,
Insured Zip
Is this a trust?	--choose-- Yes No
Trustee Name:
Trustee Mailing Address:
Trustee Mailing City:
Trustee Mailing State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Trustee Mailing Zip:
Would you like a finance quote?
Agency Address
Agency City
Agency State
Agency Zip
If the insured lives out of state, is there a management company used?	--choose-- N/A Yes No
Management Company Name:
Management Company Phone Number:

Effective Date
Proposed Effective Date:

Location #1 Remove Location
Dwelling Address:
Dwelling City:
Dwelling State:	--choose-- MD NC PA VA
Dwelling Zip Code:
Protection Class:*	--choose-- 1 2 3 4 5 6 7 8 9 10
	* If you do not choose a protection class, your quote is not valid and cannot be honored by Commonwealth Underwriters.
Replacement Cost?	$
Is Dwelling in Good Condition?	--choose-- Yes No
Does Dwelling Have any Existing Damage?	--choose-- Yes No
Is Dwelling Undergoing any Renovation or Construction?	--choose-- Yes No
Is Dwelling Rented?	Yes No
Type of Rental:	--choose-- Tenant Seasonal
Is the dwelling rented to students?	--choose-- Yes No
Are all tenants required to have renter's insurance?	--choose-- Yes No
Is this a Single Family Residence?	Yes No
Year Built:*
	* Please note: Dwellings built before 1999 must have had updates within the last 20 years to qualify for this program. Details of updates will be required on application. (Roof, Electrical, Plumbing, and Heating)
Square Footage:
Number of Stories:
Type of Construction:	Condo Doublewide on Permanent Foundation Frame Masonry Veneer Mixed - Frame and Masonry Town Home
	* Condo's cannot be quoted online, please contact Laura Fraley at 800-396-6226 x107 for assistance.
Type of Foundation:	--choose-- Permanent Masonry Pilings Pier Other
	* Please provide an explanation in the Additional Comments section at the bottom of the page
Any animals with a bite history on the premises?	--choose-- Yes No
Are there horses on premises? (If yes, quote will become submission)	--choose-- Yes No
Does the dwelling have central heating regularly serviced by a licensed professional?	--choose-- Yes No
Is there a Wood Burning Stove?	--choose-- Yes No
Is the wood burning stove the primary heat source?	--choose-- Yes No
Is there any Polybutylene or Qwest Plumbing?*	--choose-- Yes No
	* Polybutylene plumbing is flexible gray plastic piping that is put together with a crimp connector.
Any Business Pursuits on the Premises?	--choose-- Yes No
Is the dwelling located on more than 2 acres of land?	--choose-- Yes No
Any unfenced swimming pool or body of water on the premises?	--choose-- Yes No
Have there been any Repossessions in the last 3 years?	--choose-- Yes No
Is the Dwelling Located Within 1,000 Feet of the Ocean, Bay or Sound?	--choose-- Yes No
	1st Tier Coastal Counties include: Brunswick, New Hanover, Onslow, Pender, Carteret, Currituck, Dare and Hyde.
Type of roofing material:	--choose-- Asphalt shingle Metal Slate Wood shake Rubberized membrane
Is the roof flat?	--choose-- Yes No
Type of siding material:	--choose-- Aluminum Asbestos Cement Fiber EIFS Fiberglass Hardboard Composite Masonry Stucco Vinyl Wood
Year of last water heater replacement?

Update Years:
If unable to provide update year(s), leave the text field blank.
Roof	Electricity	Plumbing	Heating / AC
Is the electrical service fully updated to 100 Amp or greater, including U/L approved copper wiring, and circuit breakers of proper amperage in good condition? (Click if Yes) Does the home have any fuse boxes? (Click if Yes) Does the home have any knob and tube wiring? (Click if Yes) Does the home have any aluminum wiring? (Click if Yes) Does the home have any lead plumbing? (Click if Yes)

Loss Payee/Mortgagee

Is there a loss payee or mortgagee?	--choose-- Yes No Unknown
Is loss payee a mortgagee?	--choose-- Yes No
Does Loss Payee apply to all buildings?	--choose-- Yes No
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?	--choose-- Yes No
Loan Number
Is there another loss payee or mortgagee?	--choose-- Yes No
Is loss payee a mortgagee?	--choose-- Yes No
Does Loss Payee apply to all buildings?	--choose-- Yes No
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?	--choose-- Yes No
Loan Number
Is there another loss payee or mortgagee?	--choose-- Yes No
Is loss payee a mortgagee?	--choose-- Yes No
Does Loss Payee apply to all buildings?	--choose-- Yes No
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?	--choose-- Yes No
Loan Number
Is there another loss payee or mortgagee?	--choose-- Yes No
Is loss payee a mortgagee?	--choose-- Yes No
Does Loss Payee apply to all buildings?	--choose-- Yes No
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Loss Payee Zipcode:
Loss payee's relationship to the property?
Is there a financial interest?	--choose-- Yes No
Loan Number
Is there another loss payee or mortgagee?	--choose-- Yes No
Is loss payee a mortgagee?	--choose-- Yes No
Does Loss Payee apply to all buildings?	--choose-- Yes No
Loss Payee Name:
Loss Payee Mailing Address:
Loss Payee City:
Loss Payee State:	--choose-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Loss Payee Zipcode:
Loss payee's relationship to the property?
Loan Number
Is there a financial interest?	--choose-- Yes No

Add Another Location

Applicant:
Please choose one of the following to describe insured's credit history:	--choose-- Good Fair Poor
Has the Applicant had any Conviction of Arson or Fraud Related to any loss on Property or Insurance?	--choose-- Yes No
Has there been a Bankruptcy Within the Last Year?	--choose-- Yes No
Has there been any Foreclosure within the last Five Years?	--choose-- Yes No
Any past due Child Support?	--choose-- Yes No

Mortgage Payments:
Are Mortgage Payments Current?	--choose-- N/A Yes No

Insurance History:
Is this a new Purchase?	--choose-- Yes No
Year Purchased?
Was this a foreclosed property when purchased?	--choose-- Yes No
What was the purchase price?
Has there been any Prior Insurance on this Account?	--choose-- Yes No
Please input name of Prior Carrier:
Expiration Date of Previous/Current Insurance?:
Prior Policy Number:
Prior Policy Premium:
Risk New to Agency?	--choose-- Yes No
Was Policy Terminated at Companies' Request?	--choose-- Yes No
Has there been a Lapse of Coverage over 30 Days?	--choose-- Yes No
Previous Wind/Hail Deductible?	--choose-- 0 1 2 3 4 5
What was the Reason for Termination?	Coverage Has Never Been Cancelled or Terminated Company no Longer Writing in that Area Nonpayment of Premium Failure to Comply with Inspection Recommendations Loss History Credit History Unacceptable Animal on Premises Condition of Dwelling Insured Shopping Other
	* Please provide an explanation in the Additional Comments section at the bottom of the page

Loss History:

Any Open Claims?	--choose-- Yes No
Number of Losses in the Last Five Years:

	Date (mm|yyyy)		Type of Loss	Details	Amount Paid
1)			Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
2)			Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
3)			Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
4)			Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$
5)			Fire Water Damage - Weather Related Water Damage - Non-weather Related Wind Damage Hail Damage Theft Physical Damage - All Other Liability		$

Other Coverages:
Limit of Liability:	$0 $25,000 $50,000 $100,000 $300,000
Loss of Rents:	N/A 1000 2000 3000 4000 5000 6000 7000 8000 9000 10000 11000 12000 13000 14000 15000 16000 17000 18000 19000 20000
Owner's Contents Coverage:	1000 2000 3000 4000 5000 6000 7000 8000 9000 10000
Owner's Contents Burglary Coverage	N/A $1,000 $2,000
	Burglary Coverage cannot be applied unless a value is chosen for Owner's Contents Coverage above.
Satellite Dish Coverage
	The maximum satellite coverage available online is $3000.
Home Systems Protection Coverage: Yes No * Please note: Dwellings with a Replacement Cost > $800,000 do not qualify for this optional coverage Service Line Coverage: Yes No Identity Theft Recovery: Yes No

Credits:
Deadbolts, Smoke Alarms, Fire Extinguishers?	--select-- Yes No
Central Station Fire, Smoke and Burglar Alarms?	--select-- Yes No
Higher Deductible?	$1,000 $2,500

Commission
What commission would you like for this account?	10% 10.5% 11% 11.5% 12% 12.5% 13% 13.5% 14% 14.5% 15% 15.5% 16% 16.5% 17% 17.5% 18% 18.5% 19% 19.5% 20%

Additional Comments
Any Additional Comments:

You have an error; the incorrect field will be highlighted in red.

For higher limits or coverage options not listed, please contact Laura Fraley, Ext 107.

Any questions or problems with the form? Please contact Laura Fraley

Only Commonwealth Underwriters, Ltd. has binding authority. Coverage will not be bound until application has been received, reviewed, and accepted by Commonwealth Underwriters, Ltd.