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Salus Insurance Advisors

Home Insurance Application

Personal Information

First Name *

Last Name *

Phone *

Email *

Street Address *

City *

State *

Country *

Country

Postal Code *

Date Of Brith *

Gender *

Occupation *

Industry *

Marital Status *

Single

Married

Divorced

Widowed

Social security number? *

Property Information

Property Address Same as Mailing Address? *

Yes

No

Property Address *

Property Type *

Occupancy Type *

Number of Occupants *

Square Footage *

Year Built *

Bedrooms *

Number of Stories *

Construction Details

Construction Style *

Roof Type *

Roof Age *

Roof Design

Foundation Type *

Exterior Walls *

Heating Type *

Text (Optional)

Additional property information

Safety Features *

Smoke Detectors

Fire Extinguishers

Burglar Alarm (Monitored)

Sprinkler System

Gated Community

Coverage Information

Purchase Price and Date *

Estimated Replacement Cost *

$

Desired Dwelling Coverage Limit *

Prior Insurance History

Do you currently have homeowners insurance? *

Current Insurance Company *

Policy Expiration Date *

Years with prior carrier *

Number of Claims in Last 5 Years *

Type of Claims *

Wind/Hail

Water

Fire

Theft

Liability

Reason for No Coverage *

Upload Current Policy

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Upload All Driver's Licenses

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Mortgage & Closing Info

Is there a mortgage on the property? *

Mortgage Company Name *

Loan Number *

Closing Date *

New Purchase? *

Yes

No

Financial interest on the property to be insured *

Would you like us to review other policies for savings?

Would you like us to review other policies for savings? *

Auto Insurance

Flood Insurance

Umbrella Policy

Life Insurance

Consent & Submission

By submitting this form, I consent to be contacted by Salus Insurance Advisors via call, text, or email regarding my insurance quote. Message & data rates may apply.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Salus Insurance Advisors at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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Preferred Contact Method *

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