J. B. Lloyd & Associates, LLC 

Hazard & Homeowners Insurance Request Form

(Site Built Homes Only.  For Mobile Homes Call for Assistance) 

  INSTRUCTIONS:

  Please complete all areas of this form to simplify instant binding.

  SECTION I - APPLICANT INFORMATION:

  Applicant:         SS #:   

  Co-Applicant:    SS #:   

  Mailing Address:   

  City:                        State:                     Zip:                   

  Date of Application:                           Home Phone:                 

  Date of Loan Closing:                       Alternate Phone:

  Is property vacant?  Yes   No                 

  Premium To Be Escrowed? Yes No       

 Type of Loan:

  SECTION II - PROPERTY INFORMATION:

  Within City Limits:  Yes No     County:                     

  Property Address (If different than mailing address):                     

  City:                          State:     Zip:  

  Age of Roof:

  Manufactured Home:  Yes No       *If yes, please call 972 248-2433 to obtain a RFA form for Manufactured Homes.

 SECTION III - COVERAGE REQUEST:

                 OWNER OCCUPIED                                  NON OWNER OCCUPIED                                           VACANT 

  Dwelling/Building Amount: $   
  (Minimum amt. is 90% of Total Estimated Cost New from page 4 of Appraisal) 

BROKER/AGENT INFORMATION:


  Originator Name:                 
  Contact Person:                  
  Phone Number:                    
  Fax Number:      
  Email:               

  Confirm Email:               

INSURED'S MORTGAGE COMPANY:

  Mortgagee:  
  Address:                  
  City:                          State:                      Zip:   
  Loan No (If unknown enter UNK):                       

5228 Village Creek Drive, Suite 101 Plano, TX. 75093-4431 
Phone: 800-964-0360, ext. 205