Humana Group Eligibility - Midwest Insurance Brokerage Services Inc

Insured Person's Information

Name*

First Last

DOB*

Marital Status*

Social Security Number

Occupation*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Insured's Email

Please Select Highest Education Completed by the Insured Person*

High School
Associate's Degree
Bachelor's Degree
Law Degree
Medical Degree

Is the Insured Person an AARP Member?*

Yes
No

Add another insured Person*

No
Yes

Second Insured Person's Information

Name

First Last

DOB*

Martial Status*

Social Security Number

Occupation*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Please select the Highest Education completed by the Insured Person*

High School
Associate's Degree
Bachelor's Degree
Law Degree
Medical Degree

Is the Insured Person an AARP Member*

Yes
No

Property Information

Please select the type of quote you are seeking*

Condo
Dwelling

Condo

Property Address to be insured*

Street Address Address Line 2 City State ZIP Code

Amount to be quoted on Interior Building Property*

(100% Replacement Cost or ACV)

Amount to be quoted on Personal Property*

Liability Limit*

Medical Payments*

Deductible*

Annual Rents*

Water Back-up Limit*

(Not available with all carriers)

Sump Pump?*

Yes
No

Back-up Sump Pump system available?*

Yes
No

Identify back-up system*

Gas Powered
Water Powered
Battery Powered
Whole House Generator

How many total rental units does the insured own?*

Tenant Information

The property location is currently*

Occupied by the tenant
Vacant
Partially occupied

Year Built

Purchase Date*

Purchase Price

Number of Stories (bldg)

Number of Units (bldg)

Construction Type*

Roof Type*

Tile/Slate
Asphalt Shingle
Wood Shingle
Tar & Gravel

Square Footage

Safety Features

Please select the Safety Features the Property has*

Monitored Fire Alarm (must provide alarm certificate)
Monitored Burglar Alarm (must provide alarm certificate)
Smoke Dectectors
Fire Extinguisher(s)
Dead Bolt
None

Is the Property more than 25 years old?*

When were the utilities last updated?

If never updated, please provide the year the utility was put in the property

Furnace*

Electrical*

Plumbing*

Roof*

Please select either Breakers or Fuses*

Breakers
Fuses

Homeowners Claims

Any Homeowner Claims in the past 5 years?

Please explain (date/type of loss/amount paid)*

Mortgage

Current Mortgage Company

Mortgagee Bill?*

Yes
No

Mortgage Company Name*

Current Carrier

Number of years with Carrier

Expiration Date

Premium

Has Coverage been cancelled or non-renewed in the last 3 years?*

Please provide reason.*

Please enter any additional information you may have regarding this quote.

Dwelling

Property Address to be insured*

Street Address Address Line 2 City State ZIP Code

Amount to be quoted on Dwelling*

(100% Replacement Cost or ACV)

Amount to be quoted on Personal Property*

Liability Limit*

Medical Payments*

Deductible*

Annual Rents*

Water Back-up Limit*

Sump Pump*

Yes
No

Back-up Sump Pump System available?*

Yes
No

Identify back-up system*

Gas Powered
Water Powered
Battery Powered
Whole House Generator

How many total rental units does the insured own?*

Tenant Information

The property location is currently*

Occupied by the tenant
Vacant
Partially Vacant

Year built

Purchase Date

Purchase Price

Number of Stories

Square Footage

Number of Bathrooms

Please describe your garage

Please describe your garage*

None
Attached
Detached

Deck Square Footage

Enclosed/Open Porch Square Footage

Number of Families

Number of Families the Dwelling is*

1
2
3
4

Construction

Please select the Construction Values*

Frame
Aluminum/Vinyl
Masonry
Masonry Veneer

Foundation

Is the basement finished?

Please select the Foundation Values*

Crawl Space
Concrete Slab

Roof Type

Please select the Roof Type*

Tile/Slate
Asphalt Shingle
Wood Shingle
Tar & Gravel

Add Ons

Please select any Add-Ons the Dwelling has*

Central Heat Gas
Fireplace
WoodStove
Central Air
None

Safety Features

Please select the Safety Features the Property has*

Monitored Fire Alarm (must provide alarm certificate)
Monitored Burglar Alarm (must provide alarm certificate)
Smoke Dectectors
Fire Extinguisher(s)
Dead Bolt
None

Is the Property more than 25 years old?*

When were the utilities last updated?

If never updated, please provide the year the utility was put in the dwelling

Furnace*

Electrical*

Plumbing*

Roof*

Please select either Breakers or Fuses*

Breakers
Fuses

Homeowners Claims

Any Homeowner Claims in the past 5 years?*

No
Yes

Please Explain (date/type of loss/amount paid)*

Mortgage

Current Mortgage Company*

Current Carrier*

Number of years with Carrier*

Expiration Date*

Premium*

Has coverage been cancelled or non-renewed in the last 3 years?*

Yes
No

Please provide reason.*

Please enter any additional information you may have regarding this quote.

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Humana Group Elgibility

Step 1 of 2

Producer Information

Insured Person's Information

Second Insured Person's Information

Property Information

Condo

Tenant Information

Safety Features

When were the utilities last updated?

Homeowners Claims

Mortgage

Dwelling

Tenant Information

Please describe your garage

Number of Families

Construction

Foundation

Roof Type

Add Ons

Safety Features

When were the utilities last updated?

Homeowners Claims

Mortgage