What is your name? Last
First
Middle
What is your mailing address? Street
City
State
Zip
What is your telephone number? Home/Nighttime
Work/Daytime
What is your fax number? Fax
What is your email address? Email
What is your date of birth? Date of Birth
What is your occupation? Occupation
[ ? ]
Some occupations are eligible for professional discounts. Be sure to mention also if you work for a government agency.
How would you rate your credit? Credit
Select
Excellent
Above Average
Average
Below Average
Have you had bankruptcy, reposession or foreclosure in the past 5 years? Specify which
[ ? ]
This is to determine your eligibility with insurers.
Best time to contact
Type of insurance requested
What is the property address? Street
City
State
Zip
What is the market value of your home? Market Value
What is the dwelling type? Dwelling Type
What year was it built? Year Built
What date was the property purchased? Purchase Date
What is the construction type? Construction Type
Select
Frame
Veneer
Masonry
Concrete
Steel
Superior
Log
How many stories? Stories
Select
1
1 1/2
2
2 1/2
3
What is the total square footage of the building? Total Square Footage
What type of garage?
Select
No Carport - Garage
1 Car Carport - Attached
2 Car Carport - Attached
1-4 Car Carport - Detached
5 or More Car Carport - Detached
1-4 Car Garage - Attached
5 or More Car Garage - Attached
What type of roof?
Select
Composition Shingle
Tile
Slate
Metal
Wood Shake
Flat Tar & Gravel
Flat Membrane
Flat Foam Composite
Other
Does the building have a pool? Pool
If there is a pool, is it fenced? Pool Fence
If there is a pool, is there a diving board or a slide? Diving board or slide
What is the distance of fire protection?
Select
1000
ft or less to hydrant & 5 miles or less to fire station
Over
1000 ft to hydrant & 5 miles or less to fire station
Between 5 to 10 miles to the station
Over 10 miles to fire station
Is the building in the brush? Brush
Is there a brush hazard within 1000 feet of the building? Brush Within 1000 feet
If yes, has the brush been cleared by 250 feet from all sides of the building? Brush Cleared by 250 Feet
Is there a smoke alarm? Smoke Alarm
Is there a fire extinguisher? Fire Extinguisher
Are there deadbolts? Deadbolts
What is the heating system? Heating System
Select
Electric
Floor Furnace
Heat pump
Natural Gas
Wall Furnace
Wood Stove
Is the plumbing copper? Copper
Does the building have interior automatic fire sprinklers? Automatic Fire Sprinklers
Is there a burglar alarm? Burglar Alarm
Are there dogs on the property? Dogs on Property
If yes, how many and what is the breed of each dog?
What is the current insurance company? Current insurer
What is the expiration date of current policy? Expiration Date
What is the current premium? Current Premium
Were there any losses or claims in the last 5 years? Losses - Claims
If yes, what is the date, amount paid and description of each loss or claim?
Amount of dwelling coverage Dwelling Coverage
Liability Liability
Select
$100,000
$300,000
$500,000
Policy Deductible Amount
Select
100
250
500
750
1000
2500
5000
If earthquake insurance is requested, select deductible percentage %
Select
No Earthquake Coverage
10%
15%
20%
25%
30%
Questions or Comments
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