Name:

Email Address: 

Phone Number:

How would you wish to be contacted about your quote?:

Phone:         Email:

Address:

City:

State:

Zip Code:

Social Security Number:

Date of Birth (mm/dd/yy):

Employer:

Currently Insured with (Company not Agency):

Exp. Date of Coverage (mm/dd/yy):

What is the style of your home?:

Select OneAdobe BungalowCape Cod ColonialContemporary DuplexLog Home MediterraneanQueen Anne Raised Ranch (Bi-Level) RanchSplit Level Timber FrameTraditional Tri-LevelVictorian Other

How many stories is your home?:

Select One1 Story 1 1/2 Stories2 Stories 2 1/2 Stories3 stories 4 or more storiesBi-level Tri-Level

How many rooms are in your home?:

Select One12 345 678 9 or more

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

Roof Material:

Select OneArchitectural Shingles Asphalt ShingleBuilt Up - Tar & Gravel Clay TileConcrete Tile Corrugated SteelFiber Shingles Mineral Fiber Shakes Mission TileRock Roof Roll RoofingRubber Roof SlateTinWood Wood Shake

Exterior Material:

Select OneAdobe Aluminum SidingAsphalt Brick VeneerBrick Solid Cement FiberClapboard Concrete BlockConcrete-Precast LogsLog Siding Mineral FiberPainted Masonry Slump BlockSplit Block Stone-PrecastStone-Solid Stone-VeneerStucco-On-Frame Stucco-On-MasonryWood Shakes Wood SidingOther

Foundation Type:

Select OneSlab on Grade Crawl SpacePiers/Pilings/Stilts Unfinished Basement25% finished basement 50% finished basement 75% finished basement 100% finished basement Walkout basementWood foundation basement

Most inside walls consist of?:

Select...Brick Ceramic TileCork Grass ClothKnotty Pine MirrorPaint PanelingStone WallpaperOther

Most flooring consists of?:

Select OneCarpet over Hardwood Ceramic TileFlagstone HardwoodParquet SlateWall to Wall Carpet Other

Garage Type:

Select OneNoneAttached - 1 carAttached - 2 car Attached - 3 carBasement - 1 Car Basement - 2 CarBasement - 3 Car Built-in - 1 carBuilt-in - 2 car Built-in - 3 carCarport - 1 car Carport - 2 carCarport - 3 car Carport w/storage - 1 car Carport w/storage - 2 car Detached - 1 carDetached - 2 car Detached - 3 car

What is the replacement cost of your home?:

How many of the following do you have in your Home?:

Full Bathrooms:

Select OneNone1 23 or more

Half Bathrooms:

Select OneNone1 23 or more

Fireplaces:

Select OneNone1 23 or more

Decks:

Select OneNone1 23 or more

Enclosed Porches:

Select OneNone1 23 or more

Open Porches:

Select OneNone1 23 or more

Do you have the following in your Home?:

Swimming Pool:

Yes:         No:

Trampoline:

Yes:         No:

Burglar Alarm:

Yes:         No:

Sprinkler System:

Yes:         No:

Kerosene, Wood, or Oil Stove:

Yes:         No:

Dog (if yes what breed(s))

Yes:         No:         Breed(s):

Computer:

Yes:         No:

Livestock:

Yes:         No:

Unusual/Exotic Pet (if yes what type):

Yes:         No:         Type:

Is your home located:

Within 1000ft. of a fire hydrant:

Yes:         No:

Within 5 Miles of a fire station:

Yes:         No:

Close to a body of water susceptible to flooding:

Yes:         No:

General Questions:

Year home built:

Number of families living in the home:

Select One01 234 or more

What part of the year is the home occupied?:

Select OneYear round Seasonal (or Snowbird) OccasionalVacation None (Vacant)

Heating and Cooling System:

What term best describes your kitchen?:

Select OneEconomy StandardCustom Designer

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 five years?:

Yes:         No:

Protective Devices:

Smoke Detectors:

Yes:         No:

Fire Extinguishers:

Yes:         No:

Deadbolt Locks:

Yes:         No:

Additional Information:

Gated Community with Security Guard:

Yes:         No:

Neighborhood Watch Program:

Yes:         No:

Senior Citizen Discount (all occupants 55 or above):

Yes:         No:

Dwelling

(Coverage A - Replacement cost of your home):

$

Other Structure

(Coverage B - Typically 10% of Coverage A):

Select One$30,000 $35,100$40,250 $45,250$50,400 $55,500

Personal Property / Contents

(Coverage C - Typically 20% of Coverage A):

Select One$150,000 $165,000$180,000 $195,000$210,000 $225,000$240,000

Loss of Your Home

(Coverage D - Typically 20% of Coverage A):

Select One $60,000 $80,000$100,000 $120,000$140,000 $160,000$180,000

Personal Liability:

Select One$1,000 $2,000$3,000$4,000 $5,000$7,500 $10,000$25,000

Medical Payments:

Select One$1,000 $2,000$3,000$4,000 $5,000$7,500 $10,000$25,000

Desired Deductible:

Select One$250$500 $1,000$2,500$5,000

Additional Data:

Do you want and umbrella quote:

Select OneYesNo I don't know

Do you want a flood insurance quote:

Select OneYesNo I don't know

If you have a collection that is anything of value (such as coins, stamps, art, etc.), please specify the value or your collection:

$

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

Do you have any special interests/hobbies that could be considered a home based business:

Yes:         No:

Do you travel:

Yes:         No:

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

Yes:         No:

Where your home destroyed would you want to rebuild it on the same location?:

Yes:         No:

Do you have/want backup of sewer/drain coverage?:

Yes:         No:

Do you have/want refrigerator food spoilage coverage?:

Yes:         No: