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
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?
