|
| PERSONAL INFORMATION |
| |
| * Required Fields |
|
|
| |
| |
| INSURANCE |
| |
| Are you currently insured? |
Yes No |
| Type of Property |
|
| Occupancy |
|
| Number of Claims on any property owned in the last 36 months? |
|
| |
| |
| INFORMATION ABOUT YOUR HOME |
| |
| Construction of Home |
|
| Style of Home |
|
| Number of Stories |
(excluding basement) |
| What year was the home built? |
|
| Basement |
(excluding basement) |
| If basement is finished, square footage finished |
|
| Type of Roof |
(excluding basement) |
| Date Roof Installed |
|
| Type of heating |
|
| Date furnace installed |
|
| Electrical last updated |
|
| Garage Type |
|
| Security Features (check all that apply) |
(Central Station means connected directly to a monitoring facility) |
| |
| |
| INSURANCE COVERAGE |
| |
| If you are just purchasing home show purchase price: $ |
|
| Mortgage Amount $ |
|
| Dwelling Amount $ |
|
| Personal Property $ |
|
| Personal Liability $ |
|
| Deductible $ |
|
| Is Earthquake Coverage Requested? |
Yes No |
| Do you need specific amounts of coverage for special items (jewelry, furs, silver, etc.) |
Yes No |
| If yes, give amounts |
|
| |
| |
| UNDERWRITING QUESTIONS |
| |
| Underwriting qualification now includes credit. Credit has become a major factor in obtaining insurance in most all states, so please be aware that where applicable, rates will be quoted based on your response below. |
| Do you have a dog (If yes give breed) |
|
| Other types of insurance you would like to receive information |
|
| |
|
| |
| ADDITIONAL COMMENTS |
| |
| Please press 'Submit' button only once |
|
