Home Owners Insurance Quote Form

Home Phone & Area Code

Day   Night

Email Address
 

Current Co.

Expiration Date

Applicant Information

Location of Property if Different from Above:

Applicant's Occupation

(State nature of business if self employed)

Employer Address:

Marital Status

Date of Birth

Social Sec#

CoApplicant Information

CoApplicant's Occupation
 
(State nature of business if self employed)

Employer:

Employer Address:

Social Security #

Payment Plan

All Policies are Direct Bill  Type your choice of either 'Bill Applicant' or 'Bill Mortgagee' in the field

Rating/Underwriting Please Choose "Yes", "No" or "N/A" in all Required Fields

Frame

Choose... Yes No N/A

Year Built

Masonry

Choose... Yes No N/A

# of Rooms

Vinyl Siding

Choose... Yes No N/A

Market Value

# of Families

# Household Residents

Purchase Date

Structure Type
  Choose... Dwelling Apartment Condominium Townhouse

Deadbolt

Choose... Yes No

Fire Extinquisher
  Choose... Yes No

Visible to Neighbors

Choose... Yes No

Heat Type Primary:
Choose... Oil Natural Gas Propane Electric

Protective Smoke Device

Choose... Local Central None

Heat Type Secondary:
Choose... Oil Natural Gas Propane Electric None

Distance to Fire Hydrant

Ft.

Distance to Fire Station
Mi.

Oil Storage Tank Location

Roof Type
Choose... Asphalt Shingle Slate Wood Shingle

Swimming Pool

yes or no

Renovation Type

Please enter Yes or No in the appropriate field

Wiring

Choose... Yes No N/A

Choose... Yes No N/A

Plumbing

Choose... Yes No N/A

Choose... Yes No N/A

Heating

Choose... Yes No N/A

Choose... Yes No N/A

Roofing

Choose... Yes No N/A

Choose... Yes No N/A

Exterior Paint

Choose... Yes No N/A

Choose... Yes No N/A

General Information - Please Choose"Yes" or "No" or "n/a"

Explain all "Yes" Responses in Remarks

1. Any farming or other business conducted on premises? Including Day/Child care?

Choose... Yes No N/A

2. Any other residence owned, occupied or rented?

Choose... Yes No N/A

3. Any coverage declined, or non-renewed during the last 3 years?

Choose... Yes No N/A

4. Does Applicant or any tenant have any animals or exotic pets? (Note breed and bite history)

Choose... Yes No N/A

5. Is building undergoing renovation or reconstruction? (Give estimated completion date and dollar value)

Choose... Yes No N/A

6. Is house for sale?

Choose... Yes No N/A

7. Is there a trampoline on the premises?

Choose... Yes No N/A

Renters and Condos Only:

1. Is there a Manager on the premises?

Choose... Yes No N/A

2. Is there a security attendant?

Choose... Yes No N/A

3. Is the building entrance locked?

Choose... Yes No N/A

Remarks

Loss History

Any losses, whether or not paid by insurance, during the last 3 years at this or any other location?

Choose... Yes No N/A

Date

:Type

Amount Paid:

Description of Loss

Addditional Interest - Mortgagee

Name & Address

Loan Number

Name & Address

Loan Number

Inland Marine

Property

Amount of Insurance

Property

Amount of Insurance

Jewelry

$

Furs

$

Fine Arts

$

Musical Instruments

$

Silverware

$

Stamps

$

Policy Effective Date   

Please Note: Insurance coverage cannot be bound without a written binder from our office.