| HOMEOWNERS INSURANCE QUOTATION FORM |
| To help us supply you with the most accurate
quote possible, please answer as many questions as
you can with the most accurate information available
to you.
Information submitted will be held confidential
and will be used for quote purposes only. Submission
of application information in no way obligates you
to purchase any product or insurance, nor does it
represent any agreement to provide coverage under
any insurance policy. |
|
PERSONAL INFORMATION
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| Your
name: |
First:
Last:
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| E-mail
address: |
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| Phone
numbers: |
Daytime: |
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| Evening: |
|
| Fax: |
|
How
would you prefer to be contacted
regarding your quote? |
Phone
Fax
Mail
E-mail |
If
you would prefer to be contacted by phone,
please let us know the best time to call. |
AM
PM |
| Address: |
|
| City: |
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| State: |
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| Zip
code: |
|
| Social
Security number: |
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| Occupation: |
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| Date
of birth: |
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| Employer: |
|
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DO
YOU HAVE THE FOLLOWING IN YOUR HOME
|
|
Swimming
pool?
|
Yes
No |
|
Trampoline?
|
Yes
No |
|
Kerosene,
wood or oil stove?
|
Yes
No |
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Dog?
|
Yes
No | Breed:
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IS
YOUR HOME LOCATED
|
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Within
1000 feet from a fire hydrant?
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Yes
No |
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Within
5 miles from the firestation?
|
Yes
No |
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GENERAL
QUESTIONS
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Year home
built:
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|
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Number
of families living in the home:
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Did you
experience any loss or claims in the last 5 years?
|
Yes
No |
Date of full updates to the: |
Roof:
Plumbing:
Furnace:
Electrical:
|
|
ADDITIONAL
INFORMATION
|
|
Gated community
with a security guard:
|
Yes
No |
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Neighborhood
watch program:
|
Yes
No |
Senior citizen discount
(all occupants age 55 or above):
|
Yes
No |
|
CURRENT
HOMEOWNERS COVERAGES AND DEDUCTIBLES
|
Dwelling
(Coverage A - Replacement cost
of your home):
|
$
|
|
Other structure
(Coverage B - Typically 10% of
coverage A):
|
$
|
|
Personal
property/contents
(Coverage C - Typically 50% of
coverage A):
|
$
|
|
Loss of
use of your home
(Coverage D - Typically 20% of
coverage A):
|
$
|
|
Personal
liability:
|
$
|
|
Medical
payments:
|
$
|
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Desired
deductible:
|
$
|
|
ADDITIONAL
DATA
|
|
Quote
requested within:
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24 hrs
48 hrs
72 hrs
120 hrs |
|
Do you
want an umbrella quote:
|
|
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Do you
have/want backup of sewers and drain coverage?
|
Yes
No |
Please enter the code shown above :
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