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General Information
First Name:
Last Name:
Email Address:
Phone Numbers
Daytime:
Evening:
Fax:
Address Information
Address:
City:
State:
Zip Code:
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Owner and Home Information
Additional Applicant Information
Occupation:
Social Security Number:
Date of Birth:
Employer:
Do we have your permission to run a credit check if necessary?
Structural Information
What is the style of your home?
How many stories is your home?
How many bedrooms do you have?
What is the total square footage of the living area of your home?
What is the replacement cost of your home?
Garage Type:
How Many Do You Have of the Following?
Full Bathrooms:
3/4 Bathrooms:
Half Bathrooms:
Fireplaces:
Decks:
Enclosed Porches:
Open Porches:
Additional Structure Information
What materials are used for the following?
Roof:
Exterior of Home:
Foundation:
Most of the Inside Walls:
Most Flooring:
Additional Home Information
General Questions
Year Home Built:
Number of Families Living in Home:
What part of the year is the home occupied?
Heating System:
Cooling System:
What term best describes your kitchen?
Is business conducted on the premises?
Does anyone in your home smoke?
Did you experience any loss or claims in the last 5 years?
Additional Home Information
Your Home is Located...
...within 1000 feet from a fire hydrant:
...within 5 miles from the firestation:
...on a hillside?
...close to a body of water or susceptible to flooding?
Do You Have Any of the Following?
Swimming Pool:
Trampoline:
Kerosene, wood, or oil stove:
Dog:
- Breed:
Livestock:
Unusual/exotic pets:
Protective Devices
Burglar Alarm:
Fire Alarm:
Sprinkler System:
Smoke Detectors:
Fire Extinguishers:
Deadbolt Locks:
Additional Information
Gated Community with Guard:
Neighborhood Watch Program:
Senior Citizen Discount
(all occupants age 55 or above):
Do you have any special interests or hobbies that could be considered a home based business?
Do you have/want backup of sewers and drain coverage?
Final Information
Coverage and Deductibles Requested
Dwelling
(Coverage A - Replacement cost of your home)
Other Structure
(Coverage B - Typically 10% of coverage A)
Personal property/contents
(Coverage C - Typically 50% of coverage A)
Loss of use of your home
(Coverage D - Typically 20% of coverage A)
Personal Liability:
Medical Payments:
Desired Deductible:
Do you want an umbrella quote?
Questions and Comments
Questions/Comments: