1) Describe the property you are seeking a homeowner’s policy on:

Condominium address To Be Insured

2) Address:
     Address:

3) City:

State:

Zip Code:

4) How many individuals reside in the Condo? ---123455+

How many Children?

5) Does anyone in the household smoke?  Yes No

6) Do you have pets?  Yes No

If yes please specify:

7) How many bedrooms are in the Co-Op?

Kitchen?

Dining Room?

Living Room?

8) How many Den, Study, Office?

Family or Rec Room?

9) Is your home located within 1,000 feet of a fire hydrant?  Yes No

10) Check Items Below That Are Part Of The Residence (Please Check All That Apply):

 Deadbolt Locks Central Alarm System Central A/C Fire Extinguisher  Smoke Detectors

11) How many miles is your home located from a fire station? ---Within 5 Miles10 MilesOver 10 Miles

12) Please describe any claims you have made in the last 5 years.

Claim Type: ---Water DamageSmoke DamageFire DamageWind DamageOther
Amount($):   ---under $1,000$1,000-$2,500$2,500-$5,000over $5,000not sure

Claim Type: ---Water DamageSmoke DamageFire DamageWind DamageOther
Amount($):   ---under $1,000$1,000-$2,500$2,500-$5,000over $5,000not sure

Claim Type: ---Water DamageSmoke DamageFire DamageWind DamageOther
Amount($):   ---under $1,000$1,000-$2,500$2,500-$5,000over $5,000not sure

Claim Type: ---Water DamageSmoke DamageFire DamageWind DamageOther
Amount($):   ---under $1,000$1,000-$2,500$2,500-$5,000over $5,000not sure

The following questions concern the coverage you are requesting. Please answer them as accurately as Possible.

13) Requested deductible: $ ---100250500100020005000Not Sure

14) Requested liability coverage: $---100,000300,000500,0001 Million UmbrellaNot Sure

15) Would you like Replacement Cost Coverage on Contents?  Yes No

16) Identity Theft Coverage  Yes No

Should you make a claim, Replacement Cost Coverage gives you the replacement value rather than depreciated value for your contents. Most people have Replacement Cost Coverage.

17) Additional Coverage. Please note any scheduled personal property items or collectibles for which you need extra coverage. Please include the type and amount. For example, 'Jewelry $8,000'.

Description:
Amount($): 

Description:
Amount($): 

Description:
Amount($): 

Description:
Amount($): 

Description:
Amount($): 

The answer to these basic questions will help us process your information.

18) What range best describes your approximate household income: ---Less than $25k$25-40k$41-60k$61-80k$81-100k$101-150k$151-200k$201-300kover $300k

19) Do you own or rent your residence: ---RentOwnOther

20) Time at current residence: ---Less than 1 Year1-5 Years5-10 Years10-20 YearsOver 20 Years

21) Please describe your credit history: ---Major ProblemsSome ProblemsGoodSome LatesExcellentDon't Know

Please answer these last few questions, and we'll begin our search for the most suitable insurance policy
for you.

22) Social Security Number: (optional)

23) Date of Birth:

24) Work Telephone:

25) Best Time To Contact: ---AnytimeMorning at HomeMorning ati WorkAfternoon at HomeAfternoon at WorkEvening at HomeEvening at WorkWeekends

26) Additional Comments:
Please provide any additional information you feel is pertinent to the insurance coverage you need.

General Information:

*First Name:

*Last Name:

*Phone:        

Address:      
Address:      

City:              

*State:           ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Virgin IslandsUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

*Zip Code: