To help
us supply you with the most accurate quote possible,
please answer as many questions as you can with
the most accurate information available to you.
Information
submitted will be held confidential and will be used
for quote purposes only. Submission of application
information in no way obligates you to purchase any
product or insurance, nor does it represent any
agreement to provide coverage under any insurance
policy.
PERSONAL INFORMATION
Your
name:
First:
Last:
E-mail
address:
Phone
numbers:
Daytime:
Evening:
Fax:
How
would you prefer to be contacted
regarding your quote?
Phone
Fax
Mail
E-mail
If
you would prefer to be contacted by phone,
please let us know the best time to call.
AM
PM
Address:
City:
State:
Zip
code:
Social
Security number:
Occupation:
Date
of birth:
Employer:
STRUCTURAL
INFORMATION
What is
the style of your home?
How many
stories is your home?
How many
rooms do you have?
What is the total square
footage
of the living area of your home?
WHAT
IS THE STRUCTURE OF THE FOLLOWING
Roof:
Exterior
of your home:
Foundation:
Most of
the inside walls consist of:
Most flooring
consists of:
Garage:
What is
the replacement cost of your home:
HOW
MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
Full bathrooms:
Half bathrooms:
Fireplaces:
Decks:
Enclosed
porches:
Open porches:
DO
YOU HAVE THE FOLLOWING IN YOUR HOME
Swimming
pool?
Yes
No
Trampoline?
Yes No
Burglar
alarm?
Sprinkler
system?
Kerosene,
wood or oil stove?
Yes No
Dog?
Yes No
Computer?
Yes No
Livestock?
Yes No
Unusual/exotic
pets?
Yes No
IS
YOUR HOME LOCATED
Within
1000 feet from a fire hydrant?
Yes
No
Within
5 miles from the firestation?
Yes
No
On a hillside?
Yes No
Close to
a body of water or susceptible to flooding?
Yes
No
GENERAL
QUESTIONS
Year home
built:
Number
of families living in the home:
What part
of the year is the home occupied?
Heating
and cooling system:
What term
best describes your kitchen?
Is business
conducted on the premises?
Yes No
Does anyone
in your home smoke?
Yes No
Did you
experience any loss or claims in the last 5 years?
Yes
No
PROTECTIVE
DEVICES
Smoke detectors?
Yes No
Fire extinguishers?
Yes No
Fire alarm?
Deadbolt
locks?
Yes No
ADDITIONAL
INFORMATION
Gated community
with a security guard:
Yes No
Neighborhood
watch program:
Yes No
Senior citizen discount
(all occupants age 55 or above):
Yes No
HOMEOWNERS
COVERAGES AND DEDUCTIBLES
Dwelling
(Coverage A - Replacement cost
of your home):
$
Other structure
(Coverage B - Typically 10% of
coverage A):
$
Personal
property/contents
(Coverage C - Typically 50% of
coverage A):
$
Loss of
use of your home
(Coverage D - Typically 20% of
coverage A):
$
Personal
liability:
$
Medical
payments:
$
Desired
deductible:
$
ADDITIONAL
DATA
Quote
requested within:
24 hrs 48 hrs
72 hrs120 hrs
Do you
want an umbrella quote:
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 any special interests or hobbies that could be
considered a home based business?
Yes No
Do you
travel?
Yes
No
Do you
travel outside of the United States?
Yes
No
When you
travel, do you bring valuables such as watches, jewelry,
or furs with you?
Yes
No
Do you
buy things while traveling and want to know that they
are immediately insured under your policy?
Yes No
If your
home were destroyed, would you want to rebuild it
in the same location?
Yes No
Do you
have/want backup of sewers and drain coverage?
