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PERSONAL INFORMATION
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Name:
| First: |
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| Last: |
| E-mail
address: |
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| Phone
numbers: |
Daytime:
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Evening:
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Fax: |
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How
would you prefer to be contacted
regarding your quote? |
Phone
Fax
Mail
E-mail
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| Best
time to contact: |
AM
PM |
| Address: |
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| City: |
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| State: |
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| Zip
code: |
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| Social
security number: |
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| Occupation:
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| Date
of birth: |
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| Employer:
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STRUCTURAL
INFORMATION
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What is
the style of your home?
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How many
stories is your home?
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How many
rooms do you have?
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What is the total square
footage
of the living area of your home?
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WHAT
IS THE STRUCTURE OF THE FOLLOWING
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Roof:
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Exterior
of your home:
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Foundation:
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Most of
the inside walls consist of:
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Most flooring
consists of:
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Garage:
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What is
the replacement cost of your home:
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HOW
MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME
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Full bathrooms:
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Half bathrooms:
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Fireplaces:
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Decks:
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Enclosed
porches:
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Open porches:
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DO
YOU HAVE THE FOLLOWING IN YOUR HOME
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Swimming
pool?
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Yes
No |
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Trampoline?
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Yes
No |
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Burglar
alarm?
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Sprinkler
system?
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Kerosene,
wood or oil stove?
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Yes
No |
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Dog?
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Yes
No |
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Computer?
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Yes
No |
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Livestock?
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Yes
No |
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Unusual/exotic
pets?
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Yes
No |
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IS
YOUR HOME LOCATED
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Within
1000 feet from a fire hydrant?
|
Yes
No |
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Within
5 miles from the firestation?
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Yes
No |
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On a hillside?
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Yes
No |
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Close to
a body of water or susceptible to flooding?
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Yes
No |
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GENERAL
QUESTIONS
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Year home
built:
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Number
of families living in the home:
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What part
of the year is the home occupied?
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Heating
and cooling system:
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What term
best describes your kitchen?
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Is business
conducted on the premises?
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Yes
No |
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Does anyone
in your home smoke?
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Yes
No |
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Did you
experience any loss or claims in the last 5 years?
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Yes
No |
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PROTECTIVE
DEVICES
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Smoke detectors?
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Yes
No |
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Fire extinguishers?
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Yes
No |
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Fire alarm?
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Deadbolt
locks?
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Yes
No |
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ADDITIONAL
INFORMATION
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Gated community
with a security guard:
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Yes
No |
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Neighborhood
watch program:
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Yes
No |
Senior citizen discount
(all occupants age 55 or above):
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Yes
No |
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HOMEOWNERS
COVERAGES AND DEDUCTIBLES
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Dwelling
(Coverage A - Replacement cost
of your home):
|
$
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Other structure
(Coverage B - Typically 10% of
coverage A):
|
$
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Personal
property/contents
(Coverage C - Typically 50% of
coverage A):
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$
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Loss of
use of your home
(Coverage D - Typically 20% of
coverage A):
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$
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Personal
liability:
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$
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Medical
payments:
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$
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Desired
deductible:
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$
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ADDITIONAL
DATA
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Quote
requested within:
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24 hrs
48 hrs
72 hrs
120 hrs |
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Do you
want an umbrella quote:
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OPTIONAL
QUESTIONS
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If you
have a collection that is anything of value such as
Coins, Stamps, Art etc., specify the value of your
collection:
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$
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If you
have any furs or jewelry, please specify the approximate
value/limits:
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$
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Do you
have any special interests or hobbies that could be
considered a home based business?
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Yes
No |
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Do you
travel?
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Yes
No |
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Do you
travel outside of the United States?
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Yes
No |
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When you
travel, do you bring valuables such as watches, jewelry,
or furs with you?
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Yes
No |
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Do you
buy things while traveling and want to know that they
are immediately insured under your policy?
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Yes
No |
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If your
home were destroyed, would you want to rebuild it
in the same location?
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Yes
No |
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Do you
have/want backup of sewers and drain coverage?
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Yes
No |
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