Personal Lines Application

Complete every section that applies; enter each detail once. We'll work with you to find the best coverage across home, auto, umbrella, and other personal lines.

Attach current declarations, appraisals, MVRs, and a Statement of Values (SOV) for 3+ properties. Return by email to service@archerinsgroup.com.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Applicant / Named Insured

Date Needed / Due *

Desired Effective Date *

Referred By

Preferred Contact & Best Time

Applicant — Full Legal Name *

Date of Birth

Marital Status

SSN (optional)

Driver License # / State

Occupation / Profession

Employer

Cell Phone *

Email *

Co-Applicant / Spouse

Full Legal Name

Date of Birth

Marital Status

SSN (optional)

Driver License # / State

Occupation / Profession

Employer

Cell Phone

Mailing Address

Apt / Unit

City *

State

ZIP *

County

Time at Address

Prior Address (if < 3 yrs)

Est. Net Worth (range)

Any property held in an LLC / Trust?

If yes, entity name(s):

Household Members & Drivers List everyone in the household age 15+

Full Name

Date of Birth

Relationship

Driver License # / State

License Status

Drives? Y/N

Exclude? Y/N

Driver License # / State

License Status

Drives? Y/N

Exclude? Y/N

Driver License # / State

License Status

Drives? Y/N

Exclude? Y/N

Lines Requested Check all that apply

Homeowners / Dwelling Personal Auto Personal Umbrella

Valuables & Collections Watercraft / Boat Flood / Excess Flood

Landlord / Rental Property Life & Wealth Health / Medical

Disability Long-Term Care Identity Theft

Commercial / Business Lines

Check Commercial / Business Lines if you own a business — our commercial team will follow up for business quotes.

Other lines / Notes to our underwriter:

Residence #1 — Primary

Is Residence #1 the same address as page 1 (mailing)?

Property Address

City

State

ZIP

County

Property Details

Occupancy

Residence Type

Year Built

Living Area Sq Ft

Fin. Basement Sq Ft

Construction Type

Foundation Type

Roof Material

# Stories

Protection Class

Additional Property Features

Dist. to Fire Station (mi)

Dist. to Hydrant (ft)

Water Heater Age

Water Heater Location

Roof Shape: Hip Gable Flat Other:

Yr Roof Updated

Yr Wiring Updated

Yr Plumbing Updated

Yr HVAC Updated

Yr Electrical Updated

Solar Panels

Swimming Pool

Pool Fenced

Auto Water Shut-off Valve

Generator

Alarm / Monitoring: Central Burglar Central Fire Local Burglar Local Fire None

Mortgage? Lender / Loan #

Dog Breed / Exotic Pets

Home Coverage — Residence #1

Current Coverage

Current Carrier

Current Premium $

Policy Expiration

Yrs with Carrier

Policy Form:

HO3 (Homeowners — standard) HO5 (Premium / open peril) HO4 (Renters)

HO6 (Condo) DP3 (Rental / dwelling — special) DP1 (Rental / dwelling — basic)

Coverage Amounts

Dwelling (Cov A) $

Other Structures (B) $

Contents (C) $

Loss of Use (D) $

Liability & Deductibles

Personal Liability

Medical Payments

AOP Deductible

Wind / Hail Deductible

Flood coverage in force?

Flood Limit:

Any lapse in home coverage (last 5 yrs)?

If yes, details:

Residence #2 — Secondary / Seasonal / Rental

Address

City

State

ZIP

Use

Property Details

Months Occupied / Year

Primary Occupant (if not applicant)

Year Built

Construction

Coverage & Premium

Roof Material

Replacement Cost $

Contents $

Current Carrier

Premium $

Expiration

Mortgage? Lender / Loan #

Primary occupant e.g. parent / adult child / tenant. For 3+ residences, attach an SOV.

Vehicles Drivers are listed on page 1

Year

Make

Model

VIN

Ownership

Ann. Mi.

Primary Driver

Lienholder

Current Auto Insurance & History

Current Carrier

Policy Expiration

Current BI Limits

Current Deductibles

Current Premium $

Policy Term

Yrs Continuous Coverage

Yrs w/ Current Carrier

Any lapse in the last 5 years?

If yes, reason / dates:

Coverage Preferences & Underwriting

Desired Limits

Bodily Injury Limits

Property Damage Limits

UM / UIM

PIP

Med Pay

Deductibles & Coverages

Comprehensive Deductible

Collision Deductible

Rental Reimbursement

Roadside / Towing

Full Glass

Special Situations

Vehicle use notes, garaging (if different), lienholder addresses, or any additional auto detail:

Scheduled Valuable Articles / Collections

Attach a separate schedule with description & appraised value for each scheduled item. "Blanket" = unscheduled limit; "Scheduled" = individually listed items.

Class

Blanket Limit

Sched.? Y/N

Jewelry

Fine Arts

Silverware

Wine

Guns / Firearms

Musical Instruments

Furs

Cameras / Electronics

Other Collectibles

# Items

Highest Single Item $

Total Value $

Appraisal? Y/N

Watercraft

Year

Make & Model

Hull Value $

# Engines / HP

Top Speed

Operators

Deductible $

Hull Value $

# Engines / HP

Top Speed

Operators

Deductible $

Personal Umbrella / Excess Liability

Desired Umbrella Limit

Current Umbrella Limit

Current Umbrella Carrier

# Autos

# Watercraft

# Properties

# Drivers Under 25

# Rental Units Owned

Do you serve on any boards?

If yes, list / discussed limits with a financial advisor?

Recommended: carry personal liability at least equal to your net worth (entered on page 1).

Domestic Workers / Staff

Do you employ domestic staff (nanny, housekeeper, etc.)?

# Employed:

Role

Hours / Week

Annual Payroll

Live-in? Y/N

Workers' Comp in Place? Y/N

Live-in? Y/N

Workers' Comp in Place? Y/N

Loss History — All Lines Last 5 years

Describe all claims / losses: date, line (home / auto / etc.), type, amount, and status.

Documents to Submit

Please attach or provide the following if available:

Current declarations pages (all lines)
Claims experience / report (5 yrs)
SOV for multiple properties
Replacement-cost estimate / inspection
Prior policies / quotes
Appraisals for scheduled items
Driver list & MVRs
Photos of home(s)

Additional Comments / Explanations (include any commercial coverage interest):

Authorization & Return

Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to market my account and act as my exclusive broker for this submission. I understand that duplicate submissions by other agents can cause carriers to block access and delay or jeopardize the best available pricing.

Applicant Signature (type full name) *

Date *

Print Name

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

Your dedicated personal lines and private client team will review your submission and reach out within 1-2 business days to discuss your coverage options and get you the best available rates.