Please take five minutes of your time to find how much you can save.
 It is understood that this is not an application for insurance.
 There is no obligation and no sales person will call or visit me.

 Social Security Number: Date of Birth:    :
 Social Security Number: Date of Birth:    :
 Mailing Address / Apt/Unit # :  
 City / State / Zip:    
 Home Phone: Cell Phone:
 Fax: Work Phone / ext
 E-mail Address:

 Property Address / Apt/Unit # :  
 Are the customers non-smokers? Is coverage needed for a closing?
 Is this a waterfront property? Is this a condo unit?
 Is this property built over water? If condo what floor?
    If condo how many units?
    Name of condo association:
 Purchase Date: Mortgage Amount:
 Square Footage: Year Built:
 Number of Stories: Construction:
 Number of Families:    
 Roof Type: Heat Type:
 UPDATING DATES (Enter Date)      
 Roof: Plumbing:
 Wiring: Heating:
 Are there any animals on property? Describe animals and bite history:
 Is there a pool? Is there a trampoline on premises?
 Is there a business on premises? Has there ever been an underground oil tank?
 Is the home under construction or
Foreclosures or bankruptcies?
 Are fire hydrants within 2 blocks?    
 Number of buildings on property: Is there a basement?
 Garage or Shed: Is there a crawl space?
 Protective Devices:
 Claims in last 5 years:
 Dwelling Limit: Other structures:
 Contents Limit: Liability:
 Any Scheduled Items:
 FLOOD COVERAGE (If desired) - If built after 1975, an FEC is required in order to quote
 Dwelling Limit: Describe Garage:
 Contents Limit: Items in Garage:
 Current Carrier:
 Dwelling Coverage:
 Expiration Date:    
 Referred to us by:

 Mortgagee Name:
 Mortgagee Address:
 Mortgagee City / State/ Zip:    
 Reason for leaving current carrier:

 Your Full Name: Today's Date:   


Note: You must agree to the following terms in order to use this service.
Please read the statement below, carefully - before proceeding.


I understand that the Coastline Insurance Agency, INC. on behalf of the Insurance Company will order an investigative consumer report as part of the underwriting process to qualify, evaluate, and quote my insurance coverage. Various consumer reports such as motor vehicle reports, credit reports, and claim history with prior insurance companies, may be obtained. In the event that the coverage is denied based on information in one of these reports, I will be advised of this and given the name and address of the consumer agency making the report.

Please note: The price estimate (or quote for insurance coverage) provided to you by the Coastline Insurance Agency, INC. will be base on the information supplied by you on this application.

I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth.

WARNING: Do NOT Continue without checking the box above.
You will not be able to continue and the answers to the questions you just answered may be lost



 Coastline Insurance Agency Inc.
 1201 New Jersey Avenue
 North Wildwood, New Jersey 08260
Phone: 609-522-4515  
Fax: 609-522-9174  

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