PERSONAL INFORMATION
Your name:
First:
E-mail address:
Daytime Contact Number:
Evening:
Fax:
How would you prefer to be contacted regarding your quote?
If you would prefer to be contacted by phone, please let us know the best time to call.
Address:
City:
State:
Zip Code:
Social Security Number:
Occupation:
Date of birth:
Employer:
PRELIMINARY INFORMATION
Heating source?:
Has there ever been an underground storage tank on the premises?:
Any bankruptcies, foreclosures, liens or judgements in the last 5 years?:
Do you own a tramploine?:
Are you currently insured?:
Are you being non renewed by your current carrier for any underwriting claims or reasons?:
STRUCTURAL INFORMATION
What is the style of your home?
Select... Adobe Bungalow Cape Cod Colonial Contemporary Duplex Log Home Mediterranean Queen Anne Raised Ranch (Bi-Level) Ranch Split Level Timber Frame Traditional Tri-Level Victorian Other
How many stories is your home?
Select... 1 Story 1 1/2 Stories 2 Stories 2 1/2 Stories 3 stories 4 or more stories Bi-level Tri-Level
What is the total square footage
Owner occupied?:
WHAT IS THE STRUCTURE OF THE FOLLOWING
Roof:
Select... Architectural Shingles Asphalt Shingle Built Up - Tar & Gravel Clay Tile Concrete Tile Corrugated Steel Fiber Shingles Mineral Fiber Shakes Mission Tile Rock Roof Roll Roofing Rubber Roof Slate Tin Wood Wood Shake
Exterior of your home:
Select... Adobe Aluminum Siding Asphalt Brick Veneer Brick Solid Cement Fiber Clapboard Concrete Block Concrete-Precast Logs Log Siding Mineral Fiber Painted Masonry Slump Block Split Block Stone-Precast Stone-Solid Stone-Veneer Stucco-On-Frame Stucco-On-Masonry Wood Shakes Wood Siding Other
Foundation:
Select... Slab on Grade Crawl Space Piers/Pilings/Stilts Unfinished Basement 25% finished basement 50% finished basement 75% finished basement 100% finished basement Walkout basement Wood foundation basement
Garage:
Select... None Attached - 1 car Attached - 2 car Attached - 3 car Basement - 1 Car Basement - 2 Car Basement - 3 Car Built-in - 1 car Built-in - 2 car Built-in - 3 car Carport - 1 car Carport - 2 car Carport - 3 car Carport w/storage - 1 car Carport w/storage - 2 car Detached - 1 car Detached - 2 car Detached - 3 car
HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
Full bathrooms:
Select... None 1 2 3 or more
Half bathrooms:
Select... None 1 2 3 or more
Fireplaces:
Select... None 1 2 3 or more
Decks:
Select... None 1 2 3 or more
Enclosed porches:
Select... None 1 2 3 or more
Open porches:
Select... None 1 2 3 or more
DO YOU HAVE THE FOLLOWING IN YOUR HOME
Swimming pool?
Trampoline?
Burglar alarm?
Select... None Local Central Police station
Sprinkler system?
Select... None Some rooms All rooms
Kerosene, wood or oil stove?
Dog?
Unusual/exotic pets?
IS YOUR HOME LOCATED
Within 1000 feet from a fire hydrant?
Within 5 miles from the firestation?
Close to a body of water or susceptible to flooding?
GENERAL QUESTIONS
Year home built:
Number of families living in the home:
Select... 0 1 2 3 4 or more
Year of updating of:
Is business conducted on the premises?
Did you experience any loss or claims in the last 5 years?
PROTECTIVE DEVICES
Fire alarm?
Select... Local Central Fire station
Deadbolt locks?
HOMEOWNERS COVERAGES AND DEDUCTIBLES
Dwelling (Coverage A -
$
Medical payments:
$ Select... 1,000 2,000 3,000 4,000 5,000 7,500 10,000 25,000
Desired deductible:
OPTIONAL QUESTIONS
If you have a collection that is anything of value such as Coins, Stamps, Art etc., specify the value of your collection:
$
If you have any furs or jewelry, please specify the approximate value/limits:
$
Do you have/want backup of sewers and drain coverage?
