1) Describe the property you are seeking a homeowner’s policy on: ---Single Family Residence(Primary)Single Family Residence(Secondary)Town HomeInvestment PropertySingle Family Investment PropertyMulti FamilyCommercial

2) Address:
     Address:

3) City:

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

Zip Code:

4) What Year was the house built?

Please estimate the total square footage of the residence:

5) How many individuals reside in the home? ---123455+

6) Does anyone in the household smoke?  Yes No

7) Do you have pets?  Yes No

If Yes Please specify

8) What is the total number of floors, excluding the basement: ---123455+

9) How many bedrooms are in the home? ---11 1/222 1/233 1/244 1/255+

10) Please describe the basement: ---FinishedUnfinishedNo Basement

11) What is the total number of fireplaces in the home? ---123455+

12) Is there a garage?  Yes No

If Yes,  it is Attached it is Detached

# of cars

13) What is the style of your home? ---1 StoryRanchBi-Level2 StoryTri-LevelDuplexApartmentMulti-FamilyCondominiumTownhomeMobileNot SureOther

14) Please describe the exterior walls of structure: ---All BrickCinder BlockDrivetLogMore than 50% BrickStuccoVinyl SidingWoodWood ShinglesNot SureOther

15) Describe the type of roof on the home: ---AsphaltColored Granules (Common)Wood ShakeTreated Wood SlatsTile or Clay Shingles(Spanish Roof)MetalFlat RoofNot SureOther

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

17) 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 Swimming Pool

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

19) 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.

20) Approximate Dwelling Coverage (Replacement value less land): $

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

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

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

24) Any sewer Back-up Protection  Yes No

25) 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.

26) 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.

27) 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

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

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

30) 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.

31) Social Security Number: (optional)

32) Date of Birth:

33) Work Telephone:

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

35) 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: