Homeowners Quote
General Information
Name
Zip Code
Address
E-mail Address
City/State
Current Annual Premium (optional)
Phone (optional)
Current Insurance Company
Cell Phone
Social Security Number
How would you like us to contact you?
E-mail
Phone
Cell Phone
Residence & Coverage Information
(Coverage information can be found on the Declaration Page of your current homeowner's policy.)
Is this your primary residence?
Yes
No
Do you:
Own
Rent
If "no", what is this reidence used for? (I.E. rental, seasonal, etc.)
Current residence or new purchase
?
Current
New Purchase
Current Market Value
?
Type of Residence
Condominium
Single Dwelling
Townhouse/Row House
Other
Type of Property:
Frame/Stucco
Brick
V
eneer (over 1/2 brick veneer)
Other
Year Built
Ground Floor Square Footage
Responding Fire Department
Fireplace
?
Yes
No
Number of Stories in Home
Wood Burning Stove
?
Yes
No
Garage: Number of Cars
Attatched
Detached
Basement
Yes
No
Percent Finished
Coverage amount and liability limits on your present policy:
Current Deductible
$
$
$
eral Information
Underwriting Information
Do you have a Home Burglar Alarm ?
Yes
No
Number of Feet from Fire Hydrant (estimated)
Miles to Fire Department
Are you or your spouse over 55 years of age?
Yes
No
Any household members smoke?
Yes
No
Smoke Alarms - How Many?
Birthdates:
Yourself
Spouse
Do you currently have any scheduled items on your homeowners policy? (Jewelry, Computers, etc...)
Yes
No
If yes, please list what is scheduled and at what value:
Scheduled Item 1
Scheduled Item 2
Property Address if different than listed above:
Address:
City/State:
Zip:
Following is a list of questions for HOMEOWNERS that are required even in the comparative rater:
Year Updated / Inspected:
Wiring:
Plumbing:
Heat:
Roof:
Replacement Cost:
Dwelling:
Personal Property:
Homeowner losses in the last 3 years?
Any business conducted in the home / on the premises?
Yes:
No:
Yes:
No:
Any boats?
Recreational Vehicles?
Yes:
No:
Yes:
No:
Any Pets?
Yes:
No:
Breed?
Member of any group?
(Credit Union, College Alumni, Medical Associations, etc.)
We value your opinion. Please list any comments you have regarding the completion of this form.
We appreciate you taking the time to provide us with the requested information. We will contact you within 24 hrs. with your free, no-obligation homeowners quote.
close window
