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    Friday   07/30/2010

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Personal Homeowners Quote Request

Name:
Insured's Date of Birth:
Address:
City:
County:
Phone:
State:
Zip Code:
Renewal Date/Closing Date:
(If Renters Policy) Amount of Personal Property?
     Number of Apartments in Complex?
Current Insurance Company?
Current Limit of Insurance on Home?
Personal Property?
Liability?
Deductible?
Year of Construction?
Renovations if over 10 years old (specify year):
     Electrical?
     Plumbing?
     Roof?
     Heating?
Does home have at least 100 amp electrical service? Yes         No
Approximate Square Feet?
Number of Stories?
Construction: Brick       Frame
Woodburning Stove or a Fireplace Insert? Yes         No
Fire Extinguisher? Yes         No
Smoke Alarm? Yes         No
Security System? Yes         No
Swimming Pool? Yes         No
     If yes, Diving Board? Yes         No
     Fence? Yes         No
     Slide? Yes         No
Trampoline? Yes         No
Business conducted on the premises? Yes         No
     If yes, Type?
Any coverage desired for recreational vehicles?
Any additional coverage desired for jewelry, musical instruments, guns, furs, cameras, silver? Yes         No
     If yes, What Kind?
Any animals? Yes         No
     If yes, What Kind?
     Bites?
If located in a rural area, how many miles from the nearest fire department?
Name of responding fire department?
     Inside city limits? Yes         No
If Mobile Home, Year?
     Size?
     Is it located in a park? Yes         No
     Is it tied down? Yes         No
     Is it skirted? Yes         No
Auto insured with?
     Quote desired? Yes         No
Umbrella policy quote desired? Yes         No
Loss History:
Date Description Amount
 

 

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