| Home must be owner occupied - please note if this is a secondary/seasonal home, rental property, vacant/unoccupied dwelling, or is under major renovations/construction you need to contact our agency for quote information. |
 |
| * Required Field |
|
| Personal Information |
|
| Name*: |
|
|
| Address*: |
|
|
| City*: |
|
|
| State*: |
|
|
| Zip Code*: |
|
|
| County*: |
|
|
|
|
| Best to Contact Via*: |
|
|
|
|
| Occupation*: |
|
|
| Date of Birth*: |
(mm/dd/yyyy) |
|
Social Security Number
(optional but helpful in
eligibility and rating process): |
|
|
| Number of years residing at residency to be quoted*: |
|
|
|
|
| Current Coverage |
|
| Current Homeowner Coverage*: |
|
| If no, why?: |
|
| Current Insurance Company: |
|
|
| Expiration/Cancellation Date: |
(mm/dd/yyyy) |
|
| Years with current company: |
|
|
| Current Auto Insurance Carrier: |
|
|
| Any claims in the last 3 years: |
|
|
|
|
| Information about your home |
|
| Purchase Price of Home: |
$ |
|
| Total Mortgage Amount: |
$ |
|
| Number of families*: |
|
|
| Construction*: |
|
|
| Exterior Wall Material: |
|
|
| Style of Home*: |
|
|
| Approximate living area square footage: |
|
|
|
|
| Information about your heat |
|
| Type of Heat*: |
|
|
|
|
|
|
|
| More information about your home |
|
| Year home was built*: |
|
|
| If over 20 years old, Electrical System: |
|
|
| Total Amp Service: |
|
|
|
|
| Heating System |
|
| Age of Furnace: |
|
|
| Programmable Central Thermostat: |
|
|
|
|
| Plumbing System |
|
| Year kitchen updated: |
|
| Year oldest bathroom updated: |
|
|
| Water intake lines are all copper pipe: |
|
|
| Waste lines are all PVC pipe: |
|
|
|
|
| Information about your roof |
|
| Age of Roof: |
|
| Roof Material: |
|
|
|
|
| More information about your home |
|
| Smoke Detectors*: |
|
|
| Alarm Systems: |
|
|
| Any smokers residing in the household: |
|
|
| Number of dogs, if any?: |
|
|
| Swimming Pool: |
|
|
| Pool completely fenced in?: |
|
|
| Diving Board?: |
|
|
| Slide?: |
|
|
Any trampoline on
the property?*: |
|
|
Any business conducted
from the home address?*: |
|
|
| If so, briefly describe business: |
|
|
|
|
| Coverages |
|
| Dwelling Amount/Coverage A: |
|
|
| Other Structures/Coverage B: |
|
|
| Contents/Coverage C: |
|
|
| Loss of Use/Coverage D: |
|
|
| Personal Liability/Coverage E: |
|
|
Medical Pay to Others/
Coverage F: |
|
|
| Deductible: |
|
|
| Any valuable items to be scheduled?: |
|
|
| Jewelry(total appraisal value): |
|
|
| Furs: |
|
|
| Fine Arts: |
|
|
| Cameras: |
|
|
| Musical Instruments: |
|
|
| Other: |
|
|
| If 'other' please explain: |
|
|
| Do you own other residencies?*: |
|
|
| If yes, how many?: |
|
| Number of Family?: |
|
|
|
|
| Coverages |
|
| Other residence address 1: |
|
|
|
|
| Other residence address 2: |
|
|
|
|
| Other residence address 3: |
|
|
|
|
| Do you carry an excess liability policy?: |
|
|
| If yes, what is your limit?: |
|
|
 |
|