Application - Dominion Risk

(540) 366-7475

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GET A PERSONAL INSURANCE QUOTE

Fill out the application below to get started with Dominion Risk Advisors today. The application comes with no obligation. Give us a call at (540) 366.7475 if you have questions or need additional information.

Personal Insurance Questionnaire

Send questions to Mark Lowman at MLowman@domrisk.com. Thanks!

Full Name of Insured (Primary Applicant)*
First Last
Email*
Primary Phone*
Date of Birth (Primary Applicant)*
Driver's License Number (Primary Applicant)*
Occupation*
Highest Level of Education Obtained*
Name of Spouse (if applicable)
First Last
Date of Birth (Spouse)
MM slash DD slash YYYY
Driver's License Number (Spouse)
Occupation (Spouse)
Home Information
For dwelling to be insured
Address*
Street Address City State ZIP Code
Length of Time at Address*
If you have lived at your house for less than four years, what was your previous address?
Year Built
Square Feet (No Basement)
Date of Last Update - Wiring
Date of Last Update - Roof
Date of Last Update - Plumbing
Date of Last Update - Heating
Home Protections
Check all that apply.
- Fire Alarm Centrally Monitored
- Burglar Alarm Centrally Monitored
- Smoke Detectors
- Dead Bolts
- Fire Extinguisher
- Community Security Service or Gate
- Backup Generator
- Water Leak Detection System
Do you have the following?
Check all that apply.
- Trampoline
- Wood Stove
- Swimming Pool
- Fence Around Swimming Pool
- Slide in Swimming Pool
- Home with Galvanized Pipes
- Knob and Tube WIring in House
- Dogs or exotic animals
Type of pets
Auto Information
Please fill out for each additional driver in the household (not listed above).
Driver 3
First Last
Date of Birth 3
MM slash DD slash YYYY
Driver's License Number 3
Driver 4
First Last
Date of Birth 4
MM slash DD slash YYYY
Driver's License Number 4
Accidents
Have you had any homeowners’ claims in the past six years?*
- Yes
- No
Have any of the drivers above had any car accidents or tickets in the past three years?*
- Yes
- No
Please share additional information that may be helpful.
Are there specifics of claims about which we should know? Do you have boats, valuables, recreational vehicles or secondary residences that you need to insure?
Consent
Many of the insurance companies we will approach on your behalf will be checking your credit score as a part of the quoting / application process. By checking here, you acknowledge and authorize that credit process. We will not see a copy of your credit report.
Check to authorize the credit process.
Comments
This field is for validation purposes and should be left unchanged.

PRINTABLE APPLICATION

Download the application and email it back to us for a no-risk, no obligation insurance quote today.

DOWNLOAD THE APPLICATION

Personal Insurance

From your home and auto to your farm or recreational vehicle, we can address your needs and exceed your expectations.

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The DRA Difference

Dominion Risk Advisors provides unmatched service, advocacy and advice.

Dominion Risk Advisors

28A Kirk Avenue, S.W., Roanoke, VA 24011
540-366-7475
855-366-7475
service@domrisk.com

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