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.
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PERSONAL INFORMATION
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| Your
name: |
First:
Last:
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| E-mail
address: |
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| Phone
numbers: |
Daytime:
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| Evening:
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| Fax: |
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How
would you prefer to be contacted
regarding your quote? |
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If
you would prefer to be contacted by phone,
please let us know the best time to call. |
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| Address: |
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| City: |
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| State: |
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| Zip
code: |
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| Social
Security number: |
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| Occupation:
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| Date
of birth: |
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| Employer:
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STRUCTURAL
INFORMATION
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What is
the style of your home?
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How many
stories is your home?
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How many
rooms do you have?
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What is the total square
footage
of the living area of your home?
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WHAT
IS THE STRUCTURE OF THE FOLLOWING
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Roof:
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Exterior
of your home:
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Foundation:
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Most of
the inside walls consist of:
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Most flooring
consists of:
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Garage:
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What is
the replacement cost of your home:
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HOW
MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
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Full bathrooms:
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Half bathrooms:
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Fireplaces:
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Decks:
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Enclosed
porches:
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Open porches:
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DO
YOU HAVE THE FOLLOWING IN YOUR HOME
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Swimming
pool?
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Trampoline?
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Burglar
alarm?
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Sprinkler
system?
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< |
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Kerosene,
wood or oil stove?
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Dog?
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Computer?
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Livestock?
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Unusual/exotic
pets?
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IS
YOUR HOME LOCATED
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Within
1000 feet from a fire hydrant?
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Within
5 miles from the firestation?
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On a hillside?
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Close to
a body of water or susceptible to flooding?
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GENERAL
QUESTIONS
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Year home
built:
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Number
of families living in the home:
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What part
of the year is the home occupied?
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Heating
and cooling system:
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What term
best describes your kitchen?
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Is business
conducted on the premises?
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Does anyone
in your home smoke?
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Did you
experience any loss or claims in the last 5 years?
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PROTECTIVE
DEVICES
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Smoke detectors?
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Fire extinguishers?
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Fire alarm?
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Deadbolt
locks?
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ADDITIONAL
INFORMATION
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Gated community
with a security guard:
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Neighborhood
watch program:
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Senior citizen discount
(all occupants age 55 or above):
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HOMEOWNERS
COVERAGES AND DEDUCTIBLES
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Dwelling
(Coverage A - Replacement cost
of your home):
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$
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Other structure
(Coverage B - Typically 10% of
coverage A):
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Personal
property/contents
(Coverage C - Typically 50% of
coverage A):
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Loss of
use of your home
(Coverage D - Typically 20% of
coverage A):
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Personal
liability:
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Medical
payments:
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Desired
deductible:
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ADDITIONAL
DATA
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Quote
requested within:
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Do you
want an umbrella quote:
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OPTIONAL
QUESTIONS
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If you
have a collection that is anything of value such as
Coins, Stamps, Art etc., specify the value of your
collection:
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$
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If you
have any furs or jewelry, please specify the approximate
value/limits:
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Do you
have any special interests or hobbies that could be
considered a home based business?
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Do you
travel?
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Do you
travel outside of the United States?
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When you
travel, do you bring valuables such as watches, jewelry,
or furs with you?
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Do you
buy things while traveling and want to know that they
are immediately insured under your policy?
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If your
home were destroyed, would you want to rebuild it
in the same location?
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Do you
have/want backup of sewers and drain coverage?
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