If your mailing address is different from above, please provide:
CURRENT INSURANCE INFORMATION:
Company Name:
Current Annual Premium:
Expiration Date:
Deductible Desired:
Amount of Liability:
Earthquake Coverage Desired?
Yes
No
Have you filed for bankruptcy within the past 7 years?
Yes
No
DWELLING INFORMATION:
Estimated Replacement Cost:
Square Footage:
Year Constructed:
How Many Floors:
If other number of floors was selected, please provide a descrption:
Type of Construction:
If other type of construction was selected, please describe:
Garage:
If other garage was selected, please describe:
Type of Roof:
If other roof type was selected, please describe:
Number of Bathrooms:
Type of Heat:
If other type of heat was selected, please describe:
Do you have air conditioning?
Yes
No
Do you live within city limits?
Yes
No
Number of Acres:
Do you have any Animals?
Yes
No
If you have animals, please list how many and provide a description:
Other Features:
(check all that apply)
Deadbolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Woodstove
Fireplace
Porch
Deck
Finished Basement
Unfinished Basement
Outbuildings (shop/barn/shed)
Swimming Pool
Trampoline
CLAIMS:
List any claims in the last 5 years:
Date of Claim
Amount Paid
Claim Type
Description
1.
2.
3.
PERSONAL PROPERTY:
Jewelry and Watches:
Furs:
Silver:
Stamp and Coin Collections:
Fine Arts and Breakable Items:
ADDITIONAL COMMENTS AND REMARKS:
Who were you referred by?
Are you already working with one of our agents?
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No
If yes, who?
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