{"title":"Homeowners Insurance Proposal Request","description":"Please have detailed property information available, including roof, alarm, plumbing, heating and electrical system updates.","showQuestionNumbers":"off","showProgressBar":"top","progressBarType":"pages","checkErrorsMode":"onValueChanged","widthMode":"responsive","completeText":"Submit Application","pageNextText":"Next","pagePrevText":"Back","pages":[{"name":"owners","title":"Property Owner Information","elements":[{"name":"owner__name","title":"Name","isRequired":true,"description":"First & Last","type":"text"},{"name":"owner__how_found_us","title":"How did you find us?","isRequired":true,"type":"radiogroup","choices":["Search engines","Social media","News story","Referral","I am a current client of Susman Insurance"]},{"name":"owner__referral_name","title":"Name of Referral","isRequired":true,"type":"text","visibleIf":"{owner__how_found_us} = 'Referral'"},{"name":"owner__working_with_agent","title":"Are you working with one of our Agents?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"owner__agent_name","title":"Agent’s name","isRequired":true,"type":"text","visibleIf":"{owner__working_with_agent} = 'Yes'"},{"name":"owner__cell_phone","title":"Cell Phone","isRequired":true,"type":"text","inputType":"tel","validators":[{"type":"regex","regex":"^\\D*(\\d\\D*){10,}$","text":"Please enter a valid phone number (at least 10 digits)."}]},{"name":"owner__home_phone","title":"Home Phone","isRequired":true,"type":"text","inputType":"tel","validators":[{"type":"regex","regex":"^\\D*(\\d\\D*){10,}$","text":"Please enter a valid phone number (at least 10 digits)."}]},{"name":"owner__email","title":"Email Address","isRequired":true,"type":"text","inputType":"email","validators":[{"type":"email"}]},{"name":"owner__dob","title":"Date of Birth","isRequired":true,"type":"text","inputType":"text","maskType":"datetime","maskSettings":{"pattern":"mm/dd/yyyy","saveMaskedValue":false},"placeholder":"MM/DD/YYYY","description":"Use Month/Day/Year (MM/DD/YYYY)."},{"name":"owner__sex","title":"Sex","isRequired":true,"type":"radiogroup","choices":["Male","Female"],"showOtherItem":true},{"name":"owner__ssn","title":"Social Security Number (Skip if in California)","isRequired":false,"type":"text"},{"name":"owner__occupation","title":"Occupation","isRequired":true,"type":"text"},{"name":"owner__marital_status","title":"Marital Status","isRequired":true,"type":"dropdown","choices":["Single","Married","Divorced","Widowed"]},{"name":"spouse__name","title":"Name of Spouse","isRequired":true,"type":"text","visibleIf":"{owner__marital_status} = 'Married'"},{"name":"spouse__cell_phone","title":"Cell Phone Number of Spouse","isRequired":true,"type":"text","inputType":"tel","validators":[{"type":"regex","regex":"^\\D*(\\d\\D*){10,}$","text":"Please enter a valid phone number (at least 10 digits)."}],"visibleIf":"{owner__marital_status} = 'Married'"},{"name":"spouse__email","title":"Email Address of Spouse","isRequired":true,"type":"text","inputType":"email","validators":[{"type":"email"}],"visibleIf":"{owner__marital_status} = 'Married'"},{"name":"spouse__dob","title":"Date of Birth of Spouse","isRequired":true,"type":"text","inputType":"text","visibleIf":"{owner__marital_status} = 'Married'","maskType":"datetime","maskSettings":{"pattern":"mm/dd/yyyy","saveMaskedValue":false},"placeholder":"MM/DD/YYYY","description":"Use Month/Day/Year (MM/DD/YYYY)."},{"name":"spouse__gender","title":"Gender of Spouse","isRequired":true,"type":"dropdown","choices":["Male","Female"],"visibleIf":"{owner__marital_status} = 'Married'"},{"name":"spouse__occupation","title":"Occupation of Spouse","isRequired":true,"type":"text","visibleIf":"{owner__marital_status} = 'Married'"}]},{"name":"property_overview","title":"Property Overview","elements":[{"type":"panel","name":"property_address","title":"Property Address","elements":[{"type":"text","name":"property_address__address","title":"Address","isRequired":true},{"type":"text","name":"property_address__address_line_2","title":"Address line 2","isRequired":false},{"type":"text","name":"property_address__city","title":"City/Town","isRequired":true},{"type":"text","name":"property_address__state","title":"State/Region/Province","isRequired":true},{"type":"text","name":"property_address__zip_code","title":"Zip/Post Code","isRequired":true,"validators":[{"type":"regex","regex":"^\\d{5}(-\\d{4})?$","text":"Please enter a valid ZIP code."}]},{"type":"text","name":"property_address__country","title":"Country","isRequired":false}],"description":"Please type full property address incl. city, state and zip code"},{"name":"home__have_you_had_any_claims_in_the_last_5_years","title":"Have you had any claims in the last 5 years?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__is_the_mailing_address_same_as_property_address","title":"Is the Mailing address same as property address?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"type":"panel","name":"mailing_address","title":"Mailing Address","elements":[{"type":"text","name":"mailing_address__address","title":"Address","isRequired":true,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"},{"type":"text","name":"mailing_address__address_line_2","title":"Address line 2","isRequired":false,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"},{"type":"text","name":"mailing_address__city","title":"City/Town","isRequired":true,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"},{"type":"text","name":"mailing_address__state","title":"State/Region/Province","isRequired":true,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"},{"type":"text","name":"mailing_address__zip_code","title":"Zip/Post Code","isRequired":true,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'","validators":[{"type":"regex","regex":"^\\d{5}(-\\d{4})?$","text":"Please enter a valid ZIP code."}]},{"type":"text","name":"mailing_address__country","title":"Country","isRequired":false,"visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"}],"description":"Please type full mailing property address incl. city, state and zip code","visibleIf":"{home__is_the_mailing_address_same_as_property_address} = 'No'"},{"name":"home__dwelling_style","title":"Dwelling Style","isRequired":true,"type":"dropdown","choices":["single family","duplex","triplex","fourplex","none"]},{"name":"home__occupancy_type","title":"Occupancy type","isRequired":true,"type":"dropdown","choices":["Primary home","Secondary home"]},{"name":"home__is_there_a_basement","title":"Is there a Basement?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__what_of_basement_is_finished","title":"What % of basement is finished?","isRequired":true,"type":"text","visibleIf":"{home__is_there_a_basement} = 'Yes'"}]},{"name":"purchase_and_insurance","title":"Purchase & Prior Insurance","elements":[{"name":"home__are_you_in_escrow","title":"Are you in escrow?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__will_you_be_moving_in_within_30_days","title":"Will you be moving in within 30 days?","isRequired":true,"type":"radiogroup","choices":["Yes","No"],"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"name":"home__reason_for_not_moving_in_within_30_days","title":"Please explain why you will not be moving in within 30 days.","isRequired":true,"type":"text","visibleIf":"{home__are_you_in_escrow} = 'Yes' and {home__will_you_be_moving_in_within_30_days} = 'No'"},{"name":"home__closing_date_of_escrow","title":"Closing date of escrow","isRequired":true,"type":"text","inputType":"text","visibleIf":"{home__are_you_in_escrow} = 'Yes'","maskType":"datetime","maskSettings":{"pattern":"mm/dd/yyyy","saveMaskedValue":false},"placeholder":"MM/DD/YYYY","description":"Use Month/Day/Year (MM/DD/YYYY)."},{"name":"home__how_will_title_be_held_insured_names_trust_llc","title":"How will title be held (insured names, trust, LLC?)","isRequired":true,"type":"text","visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"name":"home__how_will_the_property_be_occupied","title":"How will the property be occupied?","isRequired":true,"type":"radiogroup","choices":["Owner","Tenant","Vacant","Short term rental"],"showOtherItem":true,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"name":"home__purchase_price","title":"Purchase price","isRequired":true,"description":"$","type":"text","inputType":"number","visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"type":"panel","name":"current_address","title":"Your Current Address","elements":[{"type":"text","name":"current_address__address","title":"Address","isRequired":true,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"type":"text","name":"current_address__address_line_2","title":"Address line 2","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"type":"text","name":"current_address__city","title":"City/Town","isRequired":true,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"type":"text","name":"current_address__state","title":"State/Region/Province","isRequired":true,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"type":"text","name":"current_address__zip_code","title":"Zip/Post Code","isRequired":true,"visibleIf":"{home__are_you_in_escrow} = 'Yes'","validators":[{"type":"regex","regex":"^\\d{5}(-\\d{4})?$","text":"Please enter a valid ZIP code."}]},{"type":"text","name":"current_address__country","title":"Country","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'Yes'"}],"description":"Please type full current address incl. city, state and zip code","visibleIf":"{home__are_you_in_escrow} = 'Yes'"},{"name":"home__purchase_date_month_and_year_only","title":"Purchase date  (Month and year only)","isRequired":true,"type":"text","visibleIf":"{home__are_you_in_escrow} = 'No'","placeholder":"MM/YYYY","description":"Use Month/Year (MM/YYYY); a day is not requested."},{"name":"home__purchase_price_2","title":"Purchase price","isRequired":true,"type":"text","inputType":"number","visibleIf":"{home__are_you_in_escrow} = 'No'"},{"type":"panel","name":"previous_address","title":"Previous address if less than 5 years","elements":[{"type":"text","name":"previous_address__address","title":"Address","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'"},{"type":"text","name":"previous_address__address_line_2","title":"Address line 2","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'"},{"type":"text","name":"previous_address__city","title":"City/Town","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'"},{"type":"text","name":"previous_address__state","title":"State/Region/Province","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'"},{"type":"text","name":"previous_address__zip_code","title":"Zip/Post Code","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'","validators":[{"type":"regex","regex":"^\\d{5}(-\\d{4})?$","text":"Please enter a valid ZIP code."}]},{"type":"text","name":"previous_address__country","title":"Country","isRequired":false,"visibleIf":"{home__are_you_in_escrow} = 'No'"}],"description":"Please type full previous address incl. city, state and zip code","visibleIf":"{home__are_you_in_escrow} = 'No'"},{"name":"home__do_you_have_a_prior_insurance","title":"Do you have a prior insurance?","isRequired":true,"type":"radiogroup","choices":["Yes","No"],"visibleIf":"{home__are_you_in_escrow} = 'No'"},{"name":"home__who_is_the_property_currently_insured_with","title":"Who is the property currently insured with","isRequired":true,"type":"comment","visibleIf":"({home__are_you_in_escrow} = 'No') and {home__do_you_have_a_prior_insurance} = 'Yes'"},{"name":"home__is_your_policy_currently_being_non_renewed","title":"Is your policy currently being non-renewed?","isRequired":true,"type":"radiogroup","choices":["Yes","No"],"visibleIf":"({home__are_you_in_escrow} = 'No') and {home__do_you_have_a_prior_insurance} = 'Yes'"},{"name":"home__reason_for_non_renewal","title":"Reason for non-renewal","isRequired":true,"type":"text","visibleIf":"({home__are_you_in_escrow} = 'No') and {home__do_you_have_a_prior_insurance} = 'Yes' and {home__is_your_policy_currently_being_non_renewed} = 'Yes'"},{"name":"home__expiration_date_of_current_policy","title":"Expiration date of current policy","isRequired":false,"type":"text","inputType":"text","visibleIf":"({home__are_you_in_escrow} = 'No') and {home__do_you_have_a_prior_insurance} = 'Yes'","maskType":"datetime","maskSettings":{"pattern":"mm/dd/yyyy","saveMaskedValue":false},"placeholder":"MM/DD/YYYY","description":"Use Month/Day/Year (MM/DD/YYYY)."},{"name":"home__who_is_listed_on_the_title","title":"Who is listed on the title?","isRequired":true,"type":"text","visibleIf":"{home__are_you_in_escrow} = 'No'"}]},{"name":"construction","title":"Construction Details","elements":[{"name":"home__property_year_built","title":"Property year built","isRequired":true,"type":"text","inputType":"number"},{"name":"home__square_footage_of_home","title":"Square footage of home","isRequired":true,"type":"text","inputType":"number"},{"name":"home__number_of_stories","title":"Number of stories","isRequired":true,"type":"dropdown","choices":["1","1.5","2","2.5","3 or more","none"]},{"name":"home__type_of_garage","title":"Type of garage","isRequired":true,"type":"radiogroup","choices":["Attached - Garage, with no living space above, that is connected to the home.","Detached - Garage or carport that is not connected to the home.","Basement - Garage entrance is on the same level as the basement. Only found in homes with a basement foundation.","Built in - Garage, with living space above, that is connected to the home on the ground level or first level.","Carport - Covered structure that is not enclosed which is attached to the home.","None - Do not have a garage."]},{"name":"home__number_of_cars","title":"Number of cars","isRequired":true,"type":"dropdown","choices":["1 Car","2 Cars","3 Cars","4 Cars","5 Cars","none"]},{"name":"home__type_of_roof","title":"Type of roof","isRequired":true,"type":"radiogroup","choices":["Architectural Shingle - Also known as dimensional or laminated shingles with a more textured look than asphalt-fiberglass.","Asphalt-Fiberglass- Shingles of uniform size and shape with a grit texture. Also known as 3-tab shingles","Clay or Concrete Tile -Tiles including Spanish or mission tiles. Typically found in the Southwest.","Slate - Shingles made of hard rock. Typically found on older homes.","Metal - Roof covering made of steel, aluminum or copper.","Wood - Shingles or shakes made of wood. Typically found on a sloped roof.","Comp Over Wood - Shingles or shakes made of wood with a layer of asphalt or architectural shingles on top.","Modified Polymer - Roof covering made of asphalt reinforced with plastic or rubber.","T-Lock - Shingles that interlock to resemble the letter \"T\".","Asbestos - Typically found in the Southeast. Could contain algae stains."],"showOtherItem":true},{"name":"home__roof_shape","title":"Roof shape","isRequired":true,"type":"radiogroup","choices":["Gable - Has \"A\" frames. This is a common shape.","Hip - Has 4 sides that slope down to the outer walls of the home. Resembles a pyramid shape.","Gambrel - Resembles a barn shape.","Flat - Has little or no slope. May be covered in tar, gravel, rolled, or built up material.","Shed - Has 1 slope. May be known as a half-gable roof.","Complex - Has multiple levels, slopes, angles or styles."]},{"name":"home__siding_type","title":"Siding Type","isRequired":true,"type":"radiogroup","choices":["Vinyl - Plastic material. Commonly used in newly built homes.","Aluminium/Steel - Metal material.","Brick/Masonary Veneer - Brick veneer or concrete veneer finish. Typically on frame construction.","Cement Fiber - Composite material made of sand. cement and cellulose fibers.","Clapboard - Wood boards attached in overlapping, horizontal rows. Also called lap siding, weatherboard, or bevel siding.","Stone Veneer - Stone veneer finish. Typically on frame construction.","Stucco - Cement type finish.","Wood - Hardwood material such as shingles or shakes. Excludes clapboard.","Adobe - Clay material. Typically found in the Southwest.","Asbestos - Cement siding type that contains asbestos, was popular from the 1920's to 1960's.","Exterior Insulation (EIFS) - Exterior insulation and finish system resembling stucco."],"showOtherItem":true},{"name":"home__number_of_bedrooms","title":"Number of bedrooms","isRequired":true,"type":"dropdown","choices":["1 bedroom","2 bedrooms","3 bedrooms","4 bedrooms","5 bedrooms","6 bedrooms","none"]},{"name":"home__number_of_full_bathrooms","title":"Number of full bathrooms","isRequired":true,"type":"dropdown","choices":["0","1 bathroom","2 bathrooms","3 bathrooms","4 bathrooms","5 bathrooms"]},{"name":"home__number_of_half_bathrooms","title":"Number of half bathrooms","isRequired":true,"type":"dropdown","choices":["0","1 half bathroom","2 half bathrooms","3 half bathrooms","4 half bathrooms","5 half bathrooms"]},{"name":"home__number_of_fireplaces","title":"Number of fireplaces","isRequired":true,"type":"dropdown","choices":["0","1 fireplace","2 fireplaces","3 fireplaces"]},{"name":"home__foundation_type","title":"Foundation type","isRequired":true,"type":"radiogroup","choices":["slab","crawlspace","post and pillar","basement"],"showOtherItem":true},{"name":"home__flooring_type_of_hardwood_tile_carpet_marble","title":"Flooring type (% of Hardwood, tile, carpet, marble)","isRequired":true,"type":"text"},{"name":"home__what_year_was_the_roof_updated","title":"What year was the roof updated?","isRequired":true,"type":"text","inputType":"number"},{"name":"home__what_year_was_the_electrical_system_updated","title":"What year was the electrical system updated?","isRequired":true,"type":"text","inputType":"number"},{"name":"home__is_the_property_on_circuit_breakers","title":"Is the property on circuit breakers?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__what_year_was_the_plumbing_updated","title":"What year was the plumbing updated?","isRequired":true,"type":"text","inputType":"number"},{"name":"home__what_year_was_the_heating_air_conditioning_updated","title":"What year was the heating/air conditioning updated?","isRequired":true,"type":"text","inputType":"number"}]},{"name":"safety","title":"Safety, Alarms & Solar","elements":[{"name":"home__is_there_a_pool","title":"Is there a pool or spa?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__is_pool_or_yard_fenced","title":"Is pool or yard fenced?","isRequired":true,"type":"radiogroup","choices":["Yes","No"],"visibleIf":"{home__is_there_a_pool} = 'Yes'"},{"name":"home__do_you_have_a_dog_if_so_what_is_its_breed_and_does_it_have_a_biting_hi","title":"Do you have a dog? \nIf so, what is its breed and does it have a biting history?","isRequired":true,"type":"text"},{"name":"home__does_the_home_have_a_burglar_alarm_system","title":"Does the home have a burglar alarm system?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__type_of_burglar_alarm","title":"Type of burglar alarm?","isRequired":true,"type":"radiogroup","choices":["Local -The alarm is heard in your premises, only.","Central - A system that notifies a third party monitoring company that contacts you, police, fire, or other emergency service.","Smart - A system that notifies you through email, text message or a mobile application."],"visibleIf":"{home__does_the_home_have_a_burglar_alarm_system} = 'Yes'"},{"name":"home__does_the_home_have_a_fire_alarm_system","title":"Does the home have a fire alarm system?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__type_of_fire_alarm_select_all_that_apply","title":"Type of fire alarm? (select all that apply)","isRequired":true,"type":"checkbox","choices":["Local -The alarm is heard in your premises, only.","Central - A system that notifies a third party monitoring company that contacts you, police, fire, or other emergency service.","Smoke Detector - Not applicable for tenant.","Smart - A system that notifies you through email, text message or a mobile application."],"visibleIf":"{home__does_the_home_have_a_fire_alarm_system} = 'Yes'"},{"name":"home__does_the_home_have_interior_fire_sprinkler_systems","title":"Does the home have interior fire sprinkler systems?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__water_leak_detection","title":"Water leak detection?","isRequired":true,"type":"radiogroup","choices":["No","Valve Closure","Central Monitor","Valve Closure with Central Monitor"]},{"name":"home__do_you_have_solar_panels","title":"Do you have solar panels?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__how_many_solar_panels","title":"How many solar panels?","isRequired":true,"type":"text","inputType":"number","visibleIf":"{home__do_you_have_solar_panels} = 'Yes'"},{"name":"home__are_they_owned_or_leased","title":"Are they owned or leased?","isRequired":true,"type":"radiogroup","choices":["owned","leased"],"visibleIf":"{home__do_you_have_solar_panels} = 'Yes'"}]},{"name":"additional","title":"Discounts & Additional Coverage","elements":[{"name":"home__household_employees","title":"Household employees?","isRequired":true,"type":"dropdown","choices":["Part time help","Full time help","Live in help","None"]},{"name":"home__are_you_an_aarp_member","title":"Are you an AARP member?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__aarp_member_number","title":"AARP member number?","isRequired":true,"type":"text","visibleIf":"{home__are_you_an_aarp_member} = 'Yes'"},{"name":"home__would_you_like_to_schedule_any_high_value_items","title":"Would you like to schedule any high value items?","isRequired":true,"type":"radiogroup","choices":["Jewelry","Fine Art","Collectible items","Purses","None"],"showOtherItem":true},{"name":"home__jewelry_amount","title":"Jewelry amount","isRequired":true,"type":"text","visibleIf":"{home__would_you_like_to_schedule_any_high_value_items} contains 'Jewelry'"},{"name":"home__would_you_like_a_quote_for_auto_insurance_to_get_multi_policy_discount","title":"Would you like a quote for auto insurance to get multi policy discount?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__also_quote_the_following","title":"Also quote the following","isRequired":true,"type":"dropdown","choices":["Flood insurance","Mortgage protection insurance","Life Insurance","Business Insurance","Other","None"],"visibleIf":"{home__would_you_like_a_quote_for_auto_insurance_to_get_multi_policy_discount} = 'Yes'"},{"name":"home__additional_remarks","title":"Additional remarks","isRequired":false,"description":"Please type in any additional info that is helpful about the above.","type":"comment"},{"name":"home__attach_current_home_or_auto_dec_sheet_mortgagee_info_or_alarm_certific","title":"Attach current home or auto dec sheet, mortgagee info or alarm certificates","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__file_upload","title":"File upload","isRequired":true,"type":"file","storeDataAsText":true,"maxSize":2000000,"acceptedTypes":"application/pdf,image/*","allowMultiple":false,"visibleIf":"{home__attach_current_home_or_auto_dec_sheet_mortgagee_info_or_alarm_certific} = 'Yes'"},{"name":"home__would_you_like_a_quote_for_earthquake_insurance","title":"Would you like a quote for Earthquake Insurance?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]},{"name":"home__would_you_like_a_quote_for_flood_insurance","title":"Would you like a quote for Flood Insurance?","isRequired":true,"type":"radiogroup","choices":["Yes","No"]}]}]}