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* Required Information

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you. Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

PERSONAL INFORMATION

*Your name:

*E-mail address:

Phone numbers:

Daytime: *

How would you prefer to be contacted
regarding your quote?

Phone Fax Mail E-mail

If you would prefer to be contacted by phone,
please let us know the best time to call.

AM PM

Address:

City:

State:

*Zip code:

Social security number:

xxx-xx-xxxx

We may need to run a credit check.
Do we have your permission?

Yes, please run my credit.

Occupation:

Date of birth:

Employer:

STRUCTURAL INFORMATION

What is the style of your home?

How many stories is your home?

How many rooms do you have?

What is the total square footage
of the living area of your home?

WHAT IS THE STRUCTURE OF THE FOLLOWING

Roof:

Exterior of your home:

Foundation:

Most of the inside walls consist of:

Most flooring consists of:

Garage:

What is the replacement cost of your home:

HOW MANY OF THE FOLLOWING DO YOU HAVE IN YOUR HOME

Full bathrooms:

Half bathrooms:

Fireplaces:

Decks:

Enclosed porches:

Open porches:

DO YOU HAVE THE FOLLOWING IN YOUR HOME

Swimming pool?

Yes No

Trampoline?

Yes No

Burglar alarm?

Sprinkler system?

Kerosene, wood or oil stove?

Yes No

Dog?

Yes No

Computer?

Yes No

Livestock?

Yes No

Unusual/exotic pets?

Yes No

IS YOUR HOME LOCATED

Within 1000 feet from a fire hydrant?

Yes No

Within 5 miles from the firestation?

Yes No

On a hillside?

Yes No

Close to a body of water or susceptible to flooding?

Yes No

GENERAL QUESTIONS

Year home built:

Number of families living in the home:

What part of the year is the home occupied?

Heating and cooling system:

What term best describes your kitchen?

Is business conducted on the premises?

Yes No

Does anyone in your home smoke?

Yes No

Did you experience any loss or claims in the last 5 years?

Yes No

PROTECTIVE DEVICES

Smoke detectors?

Yes No

Fire extinguishers?

Yes No

Fire alarm?

Deadbolt locks?

Yes No

ADDITIONAL INFORMATION

Gated community with a security guard:

Yes No

Neighborhood watch program:

Yes No

Senior citizen discount
(all occupants age 55 or above):

Yes No

HOMEOWNERS COVERAGES AND DEDUCTIBLES

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:

$

ADDITIONAL DATA

Quote requested within:

24 hrs 48 hrs 72 hrs 120 hrs

Do you want an umbrella quote:

OPTIONAL QUESTIONS

If you have a collection that is anything of value such as Coins, Stamps, Art etc., specify the value of your collection:

$

If you have any furs or jewelry, please specify the approximate value/limits:

$

Do you have any special interests or hobbies that could be considered a home based business?

Yes No

Do you travel?

Yes No

Do you travel outside of the United States?

Yes No

When you travel, do you bring valuables such as watches, jewelry, or furs with you?

Yes No

Do you buy things while traveling and want to know that they are immediately insured under your policy?

Yes No

If your home were destroyed, would you want to rebuild it in the same location?

Yes No

Do you have/want backup of sewers and drain coverage?

Yes No

*Coverage can not be bound or altered by this submission.