PERSONAL INFORMATION
Name:
First:
Last:
E-mail
address:
Phone
numbers:
Daytime:
Evening:
Fax:
How
would you prefer to be contacted
regarding your quote?
Phone
Fax
Mail
E-mail
Best
time to contact:
AM
PM
Address:
City:
State:
Zip
code:
Social
security number:
Occupation:
Date
of birth:
Employer:
STRUCTURAL
INFORMATION
What is
the style of your home?
Select...
Adobe
Bungalow
Cape Cod
Colonial
Contemporary
Duplex
Log Home
Mediterranean
Queen Anne
Raised Ranch
(Bi-Level)
Ranch
Split Level
Timber Frame
Traditional
Tri-Level
Victorian
Other
How many
stories is your home?
Select...
1 Story
1 1/2 Stories
2 Stories
2 1/2 Stories
3 stories
4 or more stories
Bi-level
Tri-Level
How many
rooms do you have?
Select...
1
2
3
4
5
6
7
8
9 or more
What is the total square
footage
of the living area of your home?
WHAT
IS THE STRUCTURE OF THE FOLLOWING
Roof:
Select...
Architectural
Shingles
Asphalt Shingle
Built
Up - Tar & Gravel
Clay Tile
Concrete Tile
Corrugated Steel
Fiber Shingles
Mineral Fiber
Shakes
Mission Tile
Rock Roof
Roll Roofing
Rubber Roof
Slate
Tin
Wood
Wood Shake
Exterior
of your home:
Select...
Adobe
Aluminum Siding
Asphalt
Brick Veneer
Brick Solid
Cement Fiber
Clapboard
Concrete Block
Concrete-Precast
Logs
Log Siding
Mineral Fiber
Painted Masonry
Slump Block
Split Block
Stone-Precast
Stone-Solid
Stone-Veneer
Stucco-On-Frame
Stucco-On-Masonry
Wood Shakes
Wood Siding
Other
Foundation:
Select...
Slab on Grade
Crawl Space
Piers/Pilings/Stilts
Unfinished Basement
25% finished
basement
50% finished
basement
75% finished
basement
100% finished
basement
Walkout basement
Wood foundation
basement
Most of
the inside walls consist of:
Select...
Brick
Ceramic Tile
Cork
Grass Cloth
Knotty Pine
Mirror
Paint
Paneling
Stone
Wallpaper
Other
Most flooring
consists of:
Select...
Carpet over Hardwood
Ceramic Tile
Flagstone
Hardwood
Parquet
Slate
Wall to Wall Carpet
Other
Garage:
Select...
None
Attached - 1 car
Attached - 2 car
Attached - 3 car
Basement - 1 Car
Basement - 2 Car
Basement - 3 Car
Built-in - 1 car
Built-in - 2 car
Built-in - 3 car
Carport - 1 car
Carport - 2 car
Carport - 3 car
Carport
w/storage - 1 car
Carport
w/storage - 2 car
Detached - 1 car
Detached - 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...
None
1
2
3 or more
Half bathrooms:
Select...
None
1
2
3 or more
Fireplaces:
Select...
None
1
2
3 or more
Decks:
Select...
None
1
2
3 or more
Enclosed
porches:
Select...
None
1
2
3 or more
Open porches:
Select...
None
1
2
3 or more
DO
YOU HAVE THE FOLLOWING IN YOUR HOME
Swimming
pool?
Yes
No
Trampoline?
Yes
No
Burglar
alarm?
Select...
None
Local
Central
Police station
Sprinkler
system?
Select...
None
Some rooms
All rooms
Kerosene,
wood or oil stove?
Yes
No
Dog?
Yes
No
Computer?
Yes
No
Livestock?
Yes
No
Unusual/exotic
pets?
Yes
No
IS
YOUR HOME LOCATED
Within
1000 feet from a fire hydrant?
Yes
No
Within
5 miles from the firestation?
Yes
No
On a hillside?
Yes
No
Close to
a body of water or susceptible to flooding?
Yes
No
GENERAL
QUESTIONS
Year home
built:
Number
of families living in the home:
Select...
0
1
2
3
4 or more
What part
of the year is the home occupied?
Select...
Year round
Seasonal (or
Snowbird)
Occasional
Vacation
None (Vacant)
Heating
and cooling system:
What term
best describes your kitchen?
Select...
Economy
Standard
Custom
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 5 years?
Yes
No
PROTECTIVE
DEVICES
Smoke detectors?
Yes
No
Fire extinguishers?
Yes
No
Fire alarm?
Select...
Local
Central
Fire station
Deadbolt
locks?
Yes
No
ADDITIONAL
INFORMATION
Gated community
with a security guard:
Yes
No
Neighborhood
watch program:
Yes
No
Senior citizen discount
(all occupants age 55 or above):
Yes
No
HOMEOWNERS
COVERAGES AND DEDUCTIBLES
Dwelling
(Coverage A - Replacement cost
of your home):
$
Other structure
(Coverage B - Typically 10% of
coverage A):
$
Select...
30,000
35,100
40,250
45,250
50,400
55,500
Personal
property/contents
(Coverage C - Typically 50% of
coverage A):
$
Select...
150,000
165,000
180,000
195,000
210,000
225,000
240,000
Loss of
use of your home
(Coverage D - Typically 20% of
coverage A):
$
Select...
60,000
80,000
100,000
120,000
140,000
160,000
180,000
Personal
liability:
$
Select...
100,000
200,000
300,000
400,000
500,000
750,000
1,000,000+
Medical
payments:
$
Select...
1,000
2,000
3,000
4,000
5,000
7,500
10,000
25,000
Desired
deductible:
$
Select...
250
500
1,000
2,500
5,000
ADDITIONAL
DATA
Quote
requested within:
24 hrs
48 hrs
72 hrs
120 hrs
Do you
want an umbrella quote:
Select...
Yes
No
I don't know
OPTIONAL
QUESTIONS
If you
have a collection that is anything of value such as
Coins, Stamps, Art etc., specify the value of your
collection:
$
If you
have any furs or jewelry, please specify the approximate
value/limits:
$
Do you
have any special interests or hobbies that could be
considered a home based business?
Yes
No
Do you
travel?
Yes
No
Do you
travel outside of the United States?
Yes
No
When you
travel, do you bring valuables such as watches, jewelry,
or furs with you?
Yes
No
Do you
buy things while traveling and want to know that they
are immediately insured under your policy?
Yes
No
If your
home were destroyed, would you want to rebuild it
in the same location?
Yes
No
Do you
have/want backup of sewers and drain coverage?
Yes
No