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Insured Name

SS Number

Today's Date

Month

Day

Year

Number in Household

Marital Status

Single

Married

Date of Birth

Month

Day

Year

Email

Home Phone

Cell Phone

Privacy Policy*

By submitting my phone number, I hereby authorize Lighthouse Insurance Agency LLC to communicate with me through text messaging. View our Privacy Policy here.

Occupation

Employer

Number of Years

Co-Insured Name

SS Number

Date of Birth

Month

Day

Year

Occupation

Employer

Number of Years

Property Address

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

Previous address if less than 3 years

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

Untitled

Single Family

Duplex

Triplex

Condo

Townhouse

Owner or tenant occupied?

Owner Occupied

Tenant Occupied

Estimate closing date/Exp date

Purchase Price

Loan Amount

Current/Desired Dwelling Coverage Limit

Deductibles

Liability Coverage Amount

Medical Payment Amount

Home:

Current Premium

Current Policy Number

Years with prior carrier

Prior Insurance Carrier

Current Policy Expiration

Flood:

Current Premium

Current Policy Number

Years with prior carrier

Flood zone

Current Policy Expiration

Losses or claims in the past three years on any homes owned?

Yes

No

Type of loss

Amount Paid: $

Date

Month

Day

Year

Dwelling Information

Year Built

Living Square Feet

Number of Stories

Any part of home over water?

Yes

No

What part/Square feet?

Story unit is on

How many units in building?

Has home been renovated to studs including new windows and doors?

Yes

No

What year?

Type of foundation

Slab

Piers

Open or closed foundation between piers?

Open

Closed

Pier Height

Roof type

Shingle

Metal

Other

Roof Shape

Flat

Gable

Hip

Year roof was updated

Shingle Type

Architectural

3-tab

Lighthouse Roof Diagram Renters Insurance

Water heater update year

AC/Heating update year

Wiring update year

Plumbing update year

Type of A/C & Heating

Central Unit

Window Unit

Gas

Electric

Number of A/C Units

Plumbing type

Copper

Polybutylene

Galvanized

PEX installed prior to 2006

PEX installed post-2006

Number of Bedrooms

Number of Bathrooms

Number of Fireplaces

Type of Fireplace

Gas Burning

Wood Burning

Number of cars

Carport?

Yes

No

Garage?

Yes

No

Type of garage/carport

Attached

Unattached

Flooring type (check one or multiple)

Wood

Carpet

Ceramic Tile

Vinyl

Other

% Wood

% Carpet

% Ceramic Tile

% Vinyl

% Other

Specify Other

Exterior

Wood

Stucco

Brick Veneer

Vinyl

Other

% Wood

% Stucco

% Brick Veneer

% Vinyl

% Other

Specify Other

Any interior items that may add value? (Elevator, Wet Bar, Whirlpool Tub, Sky Lights, Bay Windows, Interior French Doors)

Porches/Patios under roofline?

Yes

No

Open/Screened?

Open

Screened

Square footage of porch

Patio/Decks NOT under roof line?

Yes

No

Attached to home?

Yes

No

Open/Screened?

Open

Screened

Square footage of porch

Unattached structures (sheds, barns, fences, etc.) on property?

Unattached Structure Value

Distance to fire hydrant

Miles to fire station

Swimming pool?

Yes, in ground

Yes, above ground

No

Diving board?

Yes

No

4 ft fence w/ locking gate?

Yes

No

Slide?

Yes

No

Burglar Alarm

Monitored

Unmonitored

Fire Alarm

Monitored

Unmonitored

Fire Extinguishers?

Yes

No

Deadbolts on all exterior doors?

Yes

No

Gated Subdivision?

Yes

No

Trampoline?

Yes

No

Hot tub on premises?

Yes

No

Smokers in household?

Yes

No

Pets?

Yes

No

Breed?

Bite History?

Yes

No

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contact

802 Pine Street
Madisonville, LA 70447
steven@marcusagent.com
(985) 845-3663

Automobile
Builder’s Risk
Commercial Property
Condo Renters
Flood
General Liability
Homeowners
Marine
Worker’s Comp