PERSONAL INFORMATION Fields marked (*) are mandatory. |
First Name* | |
Last Name* | |
Street Address* | |
City* | |
State* | |
Zip Code* | |
E-mail* | |
Home Phone* | |
Work Phone | |
| Referred By | |
| If you have insurance with another carrier, please fill in company name | |
| How long have you been insured with that carrier | |
| Estimated annual premium (in USD) | |
| Date on which your policy renews | |
DWELLING INFORMATION Fields marked (*) are mandatory. |
| Address of Dwelling* | |
| City* | |
| State* | |
| Zip Code* | |
| Property Surroundings* | |
| Distance to Fire Station* | |
| Distance to Hydrant (ft)* | |
| Year Built* | |
| Property Use* | |
| Square Footage* | |
| Number of Families* | |
| Number of Stories* | |
| Purchase Date | |
| Purchase Price | |
| Estimated Current Market Value | |
| Estimated Replacement Value | |
| Construction Type | |
| Roofing Material | |
| Age of Roof | |
| Electrical Type | |
| Heating Type | |
| Number of Fireplaces | |
| Number of Baths | |
| Burglar Alarms?* | |
| Fire Alarms?* | |
| Smoke Detectors?* | |
| Fire Extinguishers* | |
| Sprinkler System?* | |
| Basement Square Footage | |
| Percentage Finished Basement | |
| Garage Type* | |
| Garage Square Footage (estimate) | |
| SwimingPool Type* | |
| Swiming Pool Fence Construction Type | |
| Diving Board? | |
The following questions will help us determine the best discounts for you |
| Have you had any reported losses during the past 3 years?* | |
| Any business conducted on premises? (including day/child care)* | |
| Any residence employees?* | |
| Has application had a foreclosure, repossession or bankruptcy during the past five years?* | |
| Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?* | |
| Is building retrofitted for earthquakes?* | |
COVERAGE INFORMATION Fields marked (*) are mandatory coverages. |
| COVERAGE | LIMITS % BASE |
| Dwelling* | |
| Other Structures* | |
| Personal Property* | |
| Loss of Use* | |
| Personal Liability* | |
| Medical payments* | |
| DEDUCTIBLES | |
| All Perils Deductible* | |
| CREDITS | |
| Non-Smoking Household? | |
|
