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Home Quote
Contact Information
Name and Name of Spouse:

Street Address:
City/State/Zip:
Home Phone:
Work Phone:
Cell Phone:

Have you ever had a bankruptcy, foreclosure, repossession, lawsuit, or DUI?
Yes      No

Home To Be Insured
Street Address:
City/State/Zip:

If Mobile Home:
Do you own or rent the land?      Rent      Own
Is the home in a park?      Yes      No
If yes, enter the park name.

Mobile Home Width and Length:

Manufacturer Name:
Model Name:
Year Built:
Serial Number:

Rating Information
What year was the home built?

What type of construction? (e.g. masonry or frame)

Distance From:		 HydrantFt.     Fire StationMi.

Number of Stories:

Roof Type: (e.g. shingle or tile)
Roof Age: (yrs)

How will your home be used?		 Primary Seasonal Rented Vacant

How many full bathrooms?

How many 1/2 bathrooms?

How many square feet?

Storm Shutters?		 Yes     No

Do you have a fireplace(s)?, Describe What Type.

Do you have a garage?		 No Yes, 1 car Yes, 2 car Yes, 3 car

If yes, choose garage type.
 		 Attached Detached Carport Built-In
 
What is your primary source of heat?

Protective Devices:
Do you have a security system?
If yes, describe what type.

Central Monitored?		 Yes     No

Have you had any losses in the past 3 years?		 Yes     No

If yes, please describe.

If no, do you have current insurance?

Do you own any pets? 		Yes  No

If yes, please describe. If one is a dog, what breed?

Any hot tub, sauna, swimming pool, trampoline, wet bar, skateboard ramp, diving board, slide, etc. If Yes, please describe. 

If swimming pool, is it screened or fenced in?		 Yes     No

Any open porch or patio? If yes, please describe.

Is patio screened?		 Yes     No     Size?

Please enter the date completed and describe any updates that have been done on the home. (i.e. new roof, electrical, heating, retrofitting, etc.)

 
If The Building Is Over 30 Years Old, Please Answer The Following:
Year Electricity Was Updated:

Is it on Circuit Breakers?

Year Plumbing Was Updated:

Copper, Galvanized, or Other Plumbing:
 

Current Insurance
Previous Carrier:
Start Date:
End Date:
How Long Insured:
Policy Number:
Being Cancelled or Non-Renewed? Yes     No

If Yes, why?
Coverage Information
Dwelling:
Contents:
Liability:
Medical Coverage:
Deductibles:
All Perils:
Wind/Hail/Storm:
Loss of Use:
 
Lien Holder
Name:
Address:
Phone:
Fax:
Loan #:
Mortgage Clause:
Legal Description:
   
Renters/Apartment
How many units in the complex?
# Units/Bldg:
What Floor?
Is there a fire wall between units? Yes     No
Is there an apartment or condo association? Yes     No
Rating Information
What year was this dwelling built?
How many sq. feet?
What type of dwelling?
What type of construction?
What is the primary source of heat?
Do you have a security system? Yes     No
Central monitored? Yes     No
If Yes, what type?
Have you had any losses in the past 3 years? Yes     No
If Yes, please describe:
Do you have renters insurance now? Yes     No
Do you own any pets? Yes     No
If Yes, please describe:
Condo Coverage Information
What is the total value of your personal property?
Do you have collections worth over $500? Yes     No
If yes, please describe:
Do you have any single
piece(s) of jewelry valued over $500?		 Yes     No
If yes, please describe:
Do you have work tools that need coverage? Yes     No
If yes, please describe:
Do you operate a business out of your residence? Yes     No
If yes, please describe:
   

Please use the space below to add comments regarding any special circumstances or coverage needs.

 

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