Request Policy Review 1Step 12Step 234 Primary Policyholder Name* First Last Phone*Email* Insured Location Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Do you have both your home/condo/renters & auto insurance with us?Home & AutoHome OnlyAuto OnlyHave you remodeled or made any updates to an existing home(s)? Yes No Please list updates below Please try to be as specific as possible. For example: Updated siding, replaced windows, put on a new asphalt shingle roof in 2022, added a hardwired generator, etc.Check any of the following you have in your household (may result in a discount on your home insurance): Free-standing generator Permanently mounted & hard-wired generator Automatic water shutoff device Water detection sensor Interior sprinkler system Low temperature monitoring alarm system Do you have solar panels? Yes No How many panels do you have & what is the total cost? Are the solar panels attached to your home or to a structure not attached to your home? Has anyone moved in or out of the household in the last 12 months? Yes No Please provide more details below: Do you have any of the following alarm systems in the household: Central Station Fire (Monitored by a 3rd Party) Central Station Burglar (Monitored by a 3rd Party) Direct Fire (Alerts Fire Station when triggered) Direct Burglar (Alerts Police Station when triggered) Local Fire (Audible alarm when triggered) Local Burglar (Audible alarm when triggered) Have you purchased any additional property in the past year? Yes No Please provide more details: What is the address? Would you like us to quote this property as well for a bundle savings? Is it a secondary, seasonal or rental property?Do you rent out your home via AirBnB, VRBO, or a similar provider? Yes No Please provide more detail: How many days per year do you rent out your home? Do you rent by night, by week, month or seasonally?Do you have any pets? Yes No Please list the breed/kind of pet(s) below & whether or not there is any bite history. Do you have any livestock? Yes No Please list the kind of livestock you have & the total number of animals. The more information the better - are the animals used for personal use only, do you breed or sell any livestock, etc.Do you have or have you installed any of the following: Pool Jacuzzi Trampoline Free Standing Woodstove Free Standing Pellet Stove Please provide more details. Inground or above ground? Is the pool fenced? Is there a locked gate? Any diving board or slide?Does the trampoline have a safety net? Yes No Do you have or have you purchased jewelry, art or other valuables that need to be added to your home policy? Are there items that need to be changed or deleted? Yes No Please describe below: Include a brief description & approximate value. Please upload or email any jewelry appraisal or bill of sale you might have for each item.Are there any other policies in your household insured elsewhere you'd like us to quote or take a look at for a bundle discount? Watercraft Motorcycle Snowmobile or ATV RV or Motorhome Secondary/Seasonal Home Life Insurance Other Would you like to see how much your home insurance premium could lower by increasing your deductible? Yes, contact me with options. No Which deductible options are you interested in? $1,000 $2,500 $5,000 $10,000 Do you currently have a mortgage on your home Yes No Do you have an Umbrella Policy? Yes No, but I would like a quote. No, I'm not interested in a quote. An umbrella policy is an extra layer of liability coverage that goes beyond the limits of your other policies (home & auto). It provides additional protection in case you or a family member are responsible for: Property damage, Personal injury to others, Certain lawsuits, Personal liability situations. Umbrella policies are generally pretty inexpensive & well worth the additional liability coverage.Do you have a Flood Policy? Yes No, but I would like a quote. No, I'm not interested in a quote. Homeowners insurance policies do not cover flooding. Over 25% of all flood claims occur outside of high risk (A & V zones) areas. About 80% of Hurricane Harvey victims did not have flood insurance, mainly because their flooded homes were not in A or V zones, so they were not required to buy it. The average flood loss over the last 3 years was $73,960. We always recommend a flood policy even if you're not in a "high risk" flood zone. The cost for a flood policy can be pretty inexpensive depending on where your home is located. Would you like to have coverage for damage to your home from an earthquake? Yes, please let me know how much it would cost to add this coverage. No, I'm all set. Almost all home insurance policies exclude coverage for earthquake damage, however they do offer the option to add the coverage as an endorsement. We recommend considering earthquake coverage - the cost to add depends on the state where your home is located & also depends on your insurance company.Have you thought about moving or purchasing a secondary residence in the next 12 months? Yes No Are you already working with a realtor? Yes No Are you already working with a loan officer? Yes No Would you like us to connect you with one of our recommended realtors or loan officers? Yes No We work with many experienced loan officers & realtors throughout New England. We would be happy to make an introduction by email or phone if you'd like to be connected. Having a good realtor, loan officer, title company & insurance agency makes the home buying process much smoother!Please explain any changes to your home or upcoming plans:Any information additional information is helpful. If you have plans to make changes to your home please let us know (for example: you plan to replace the heating system, plan to put on a new roof, plan to get rid of a trampoline, etc. Please think back over the last year when answering these questions. Do you have any children in the household that are on your auto policy or need to be listed on your auto policy soon? Yes No Please provide name, date of birth, drivers license number of new driver(s): Do any of your children qualify for a Good Student Discount? Yes No Is any driver in the household attending school located 100+ miles away from home without the use of a vehicle in your household? Yes No What is the name of your child attending school over 100 miles from home & what is the name of the school they're attending: Are there any drivers on your auto policy that are no longer in the household? Yes No Please list the name of the driver that is no longer in your household: Have you, or any driver in the household, changed your job, school location, or work from home? Yes No Please provide more details below: Have you recently added or replaced a vehicle? Yes No Please describe: Provide as much detail as you can (for example: I replaced my 2015 Chevy Silverado for a new 2023 Ford Mustang three weeks ago)Have any insured vehicles been customized or altered? Yes No Please provide more information: For example: I added custom vinyl to my Ford Mustang, total cost was $5,000.Have you considered increasing your liability limits for better protection of your assets? Yes, please provide a quote with higher limits of coverage. No We recommend carrying at least $250,000 Per Person/$500,000 Per Accident for Bodily Injury Liability & $100,000 for Property Damage Liability - if you currently have lower limits we would be happy to quote the recommended limits of coverage, it typically doesn't impact premium too much for the improved liability coverage.Have you considered increasing your comprehensive & collision deductibles for a savings? Yes, I'm interested in a quote with higher deductibles. No, I'm all set. Please quote the following deductible options for me: $500 $1,000 $2,000 Have you (or any other drivers in the household) updated your drivers license in the last year? Yes No Please provide the new updated drivers license number(s) below: Do you have a home/condo/renters policy in place? Yes, already insured through Portsmouth Atlantic Insurance! Yes, I have a policy with another company & am all set. No, but I am interested in bundling home/condo/renters with Portsmouth Atlantic Insurance for a discount. No, I don't have a home/condo/renters policy in place. Please review your policy documents to verify all information is accurate. If there is a discrepancy please notify us by contacting the office directly or filling out the last question in the questionnaire that asks if there is anything else you’d like to mention before we touch base with you.You can upload any documentation here:Max. file size: 39 MB.This includes "Declaration Pages" (coverage pages) for other policies in the household, a report card for a Good Student Discount, a copy of an updated Drivers License, etc.Anything else you'd like to mention before we touch base with you?The more information you provide the better. If you have any questions or concerns, please feel free to share here. New Hampshirements on this web site as to policies and coverages provide general information only. Insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise, e-mail, voice mail or facsimile. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed directly by a licensed agent. Any proposal of insurance we may present to you will be based upon the information you provide to us via this online form/application and/or in other communications with us. Please contact our office directly to discuss specific coverage details and your insurance needs. All coverages are subject to the terms, conditions and exclusions of the actual policy issued. Information provided on this site does not constitute professional advice; if you have legal, tax or financial planning questions, you should contact an appropriate professional. 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