Property Disclosure Form

Full Name:

Birth Date

Spouse's Name

Mailing Address

Address of the property being insured:

Name of your Mortgage Company if applicable:

Loan Number

Is your property insurance paid through an escrow account?

How do you hold title to this property?

How are you using this property?

If this is a rental property, do you use a property manager?

Have you had any property insurance claims in the past 5 years?

If there is a dog on premises has it bitten anyone?

Does the property have a pool?

Is there a trampoline on the property?

Select the deductible amount:

Requested new policy start date?

What is the age of the roof? If it has been replaced when?

Opt-In

By checking, you are granting your permission for Rightway Insurance LLC to bind coverage based on a previously

provided quote.

Failure to accurately answer the questions may result in the denial or cancelation of coverage by the insurance carrier. The

insurance carrier reserves the right to verify that the property meets their underwriting guidelines.

Coverage is not effective until it has been approved by underwriting.

(480) 988-0878