Thank you for your interest in receiving a homeowners quote from My Florida Insurance. This form should only take about 5 minutes to complete. Don't worry if you don't have everything. You can always click the "Save and continue later" button below. We'll email you a private link to pick up where you left off.

Name*

Insured First Name Insured Last Name

Mobile Phone*

Email*

Date of Birth*

Occupation*

Please specify other occupation

Date you want this policy to start*

Personal Information

Marital Status*

Significant Other Name

First Last

Significant Other Date of Birth

Significant Other Phone

Significant Other Email

Significant Other Occupation

Significant Other: Please specify other occupation

Property Information

Year Home Built*

Construction Type

Exterior Walls

Number of Stories

Is there a rental unit on the property?

Yes

No

Rental unit is

Attached

Detached

Rental Unit Usage

Roofing Material

Roof Design

Does the roof have any solar panels?*

Yes

No

How many solar panels

Current value of solar panels

Do you know when the roof, plumbing, electrical, or exterior paint was updated?*

No

Yes

I don't know

Year Roof Updated*

Year plumbing updated*

Year electrical updated*

Year ext. paint updated*

Purchase Date*

Purchase Price*

Mailing Address

Mailing Address*

Same as Property Address?

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of years at this address

Previous Address*

Street Address City State Zip Country

Replacement Cost

We need this information to determine how much it would cost to rebuild this property in the event of a loss.

Has the electrical or plumbing on your condo been updated? If so what year(s)?*

Foundation Type

Square Feet

Garage

What type of other garage does the property have?*

Full Baths

Half Baths

Bathroom Grade

Kitchen Grade

Cooling / Air

Primary Heat Source

Fireplace Types

None

Wood burning fireplace

Gas fireplace

Wood stove

How many of each type of fireplace?

Deck

Deck Sq Ft

Upload Current Policy

To better assist us in comparing your current coverage to our proposal, please upload a copy of your current homeowners policy.

Would you like to upload a copy of your current homeowners policy?*

Yes

No

Name of current insurance carrier*

Why we need this: We represent many different carriers and we don't want to quote your insurance with the same carrier.

When does your current policy expire?

Current Policy Upload*

You may upload up to 10 policy documents. Only .pdf file types accepted.

Drop files here or

Accepted file types: pdf, Max. file size: 6 MB, Max. files: 10.

Claims and Rating Information

Liability Limit

Dwelling / Improvements Coverage

Contents Coverage Amount

Loss of Use Amount

Reported Claims (last 5 years)*

Have you had any insurance lapse (30 days or more), cancel, or non-renew in the last 3 years?*

No

Yes

No prior insurance

Optional Discounts

The following discounts are available. Please check all that apply.

Please let us know what unique features this property has (ie. elevator, backup generator, server room, etc.)

Scheduled Items

Most homeowners policies have limitations on the following types of personal property. You have the option to schedule (or add) these special items to your policy for higher coverage.

Examples of these types of items include: jewelry, furs, art, collectibles, cameras, computers, golfing equipment, guns, antiques, silverware, bicycles, coins, musical instruments.

Do you have any items you would like to schedule?*

No

Yes

Please describe your items

Last Step

You're almost done!

Would you like to receive an auto quote as well to maximize your savings?*

Yes

No

Let's discuss

Would you like a quote from a specific agent?

How were you referred to us?*

Is there anything you want us to know?

Consent*

Like most insurance agencies, [agencyname] uses information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.*

Yes

Would you like to create a user account to manage your submissions?*

Yes, create my account

Not at this time

Username*

Create a Password*

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Name

This field is for validation purposes and should be left unchanged.

Personal Information

Property Information

Property Information

Mailing Address

Replacement Cost

Upload Current Policy

Claims and Rating Information

Optional Discounts

More Property Info

Scheduled Items

Last Step

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