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First Name
*
Last name
*
Social Security No.
*
Date of Birth
*
Month
/
Day
/
Year
Occupation
*
Email
Spouse/Domestic Partner First Name
Spouse/Domestic Partner Last Name
Spouse/Domestic Partner Date of Birth
Spouse/Domestic Partner Social Security No.
Spouse/Domestic Partner Occupation
Phone Number 1
Phone Number 2
Property Street Address
*
City
*
State
*
Zip Code
Do you currently insure this property?
Yes
No
Why are you presently looking for insurance? (Check all that apply).
New Purchase.
Re-Finance.
Policy Cancelled or Lapsed.
Paying too much.
Would like to improve coverage.
Prior Home Address if New Purchase/Current Address if Rental or Secondary Home
Tell us about your home.
Estimated Reconstruction Cost.
Estimated Personal Contents Value.
Year Built
When were the following components last updated?
Roof
Within 1 Year
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
More than 20 Years
Electric
Within 1 Year
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
More than 20 Years
Plumbing
Within 1 Year
Within 5 Years
Within 10 Years
Within 15 Years
Within 20 Years
More than 20 Years
Heating/HVAC
Within 1 Year
Within 5 Years
Within 10 Years
Within 20 Years
More than 20 Years
Number of Stories?
1
1.5
2
2.5
3
Bi-Level
Tri-Level
Split Level
Total Square Feet (Living Space)?
Construction Material on Exterior Walls?
Aluminum or Vinyl Siding
Asbestos or Wood Siding
EFIS, Stucco, Dri-Vit
Brick or Stone over Wood Frame
Solid Masonry
Type of Foundation?
Crawl Space
Full Basement
Cement Slab
Do you have a finished basement?
Yes
No
Roof Shape?
Hip
Gable
Flat
Peak
Number of Full Baths?
1
2
3
4
5
Number of Half Baths
1
2
3
4
Quality of Baths' Finishing?
Builder's Grade
Custom
Do you have a fireplace?
Yes
No
Do you have a Wood Burning Stove?
Yes
No
Do you have central air conditioning?
Yes
No
Heat Type
Gas
Electric
Oil
Electric Type
Circuit Breakers
Fuses
Knob & Tube
Do you have a:
Garage?
Carport?
Do you have any of the following structures?
Open Porch
Screened or enclosed patio.
Balcony or deck.
Pool
Does your pool have a slide?
Yes
No
Does your home have any of these features? Do not include if located in your basement.
Office
Full-Time employee's quarters
Custom Kitchen (Upgraded counters, cabinets, etc...)
Is your home located within 5 miles of a fire station and 1,000 feet of a fire hydrant?
Yes
No
Do you have a trampoline or tree house?
Yes
No
Does your home have any of the following safety features?
Smoke alarms
Central station burglar & fire alarm
Fire extinguishers
Internal sprinkler system
Dead bolt locks
Do you have a water backup/sump pump system?
Yes
No
Do you have a backup generator system?
Yes
No
Do you require Flood Insurance?
Yes
No
Would you like Flood Insurance?
Yes
No
Would you like Earthquake Insurance?
Yes
No
Is there existing damage to your home?
Yes
No
Please explain any existing damage.
Tell us about you.
Any personal property, such as jewelry, furs or fine art, that should be listed on your policy?
Yes
No
If yes, please describe
Tell us about your toys. Do you have any of the following:
Motorcycle
Boat
Jet Ski
RV
ATV
Other
Do any household residents smoke?
Yes
No
Do you have any pets?
Yes
No
What kind & breed?
Is this property primary/owner occupied?
Yes
No
Will the home be occupied within 30 days?
Yes
No
Do you occupy any additional properties?
Yes
No
If yes, please provide type of property & location
Have you ever had a bankruptcy?
Yes
No
Number of household members?
Is there a home-based business?
Yes
No
If yes, please describe.
Do you want a quote for Cyber Coverage?
Yes
No
Have you had any claims in the last 5 years?
Yes
No
List prior claims in the past 5 years
If you have a mortgage, please tell us the following:
Mortgage Company/Bank Name & Address
Loan Number:
Does your mortgage company/bank pay your homeowners insurance bill?
Yes
No
Auto Insurance Company:
Auto Policy Expiration Date:
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