Home Owner Insurance

Please take a moment to answer the following questions. Remember, this information is needed to find the best rate for you. so please answer it as accurately and completely as possible.



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

2) Address:
     Address:

3) City:

State:

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?

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:

9) How many bedrooms are in the home?

10) Please describe the basement:

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

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?

14) Please describe the exterior walls of structure:

15) Describe the type of roof on the home:

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?

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

Claim Type:


Amount($):   

Claim Type:


Amount($):   

Claim Type:


Amount($):   

Claim Type:


Amount($):  

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: $

22) Requested liability coverage: $

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:

28) Do you own or rent your residence:

29) Time at current residence:

30) Please describe your credit history:

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:

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:          

*Zip Code: