HOMEOWNERS INSURANCE QUESTIONAIRE
FIRST NAME 
LAST NAME
LAST NAMEPROPERTY ADDRESS
CITY STATE ZIP
STATE ZIPTYPE OF RESIDENCE RESIDENCE USE SQUARE FOOTAGE DO YOU HAVE INSURANCE NOW?
RESIDENCE USE SQUARE FOOTAGE DO YOU HAVE INSURANCE NOW?COVERAGE SECTION
LIMITS DESIRED FOR:
DWELLING
CONTENTS
LIABILITY
DISCOUNTS SECTON
CENTRAL STATION BURGLAR ALARM
CENTRAL STATION FIRE ALARM
STORM SHUTTERS
(MITIGATON INSPECTION REQUIRED FOR
SHUTTER CREDIT)
DATE OF SHUTTER INSTALL
AGE OF ROOF OR INSTALL DATE
DO YOU HAVE AUTO COVERAGE WITH TRITON INSURANCE GROUP?
HAVE YOU HAD A WINDSTORM MITIGATION INSPECTION COMPLETED FOR YOUR HOME (FOR UP TO 45% IN DISCOUNTS)?
IF YOU HAVE NOT HAD AN INSPECTION, WOULD YOU LIKE US TO HAVE A MITIGATOR CONTACT YOU?
VERY IMPORTANT MONEY SAVINGS INFORMATION: Mitigation credits for Roof Installations under Miami Dade building codes 1994 and 2002 offer approximately 25% discounts with our Insurance Carriers (mandated by the state of Florida. Additionally the shutter and roof shape discounts, can offer another 23% in discounts. The standard cost of a mitigation inspection is $150.00.
CONTACT INFORMATION
HOME PHONE
CEL PHONE
FAX NUMBER
EMAIL ADDRESS:
DUDUCTIBLES:
ALL PERILS
HURRICANE
COMMENTS / REMARKS:
Wind Mitigation Section:Date of roof Installation-
Date of roof Installation-Roof Covering- Meets FBC Equivalent
Roof Deck Attachments-
Roof Deck Attachment-
Roof Shape-
Opening Protection-
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