ONLINE HOME OWNER'S QUOTE FORM


Applicant Name

Address

City
State / Zip /
County
Home Phone - -
Work - -
Fax - -
E-Mail
Social Security # - -
Co-applicant Name

Please list previous address (if less than 3 years):

 

Applicant Information

Applicant's Occupation Applicant's Employer Yrs. Empl Martial DOB Social Security#

 

Coverage Liability

HO Form:  
Dwelling: Other Structures:   
Loss of Use: Personal Prop:
Personal Liability:  Medical Payments:

 

Deductibles

All Peril: $ Wind/Hail: $ Theft: $

 

RATING/UNDERWRITING

Construction Type: Year Built:
Structure Type: Square Foot:
Usage Type: Weeks Rented:
Replacement Cost: $ Market Value: $
Number Rooms: Number Apartments:
Number of Families:  

Renovation Type Partial Full Year
Wiring
Plumbing
Heating
Roofing
Exterior Paint

Swimming Pool
Approved Fence Yes No
Non-Approved Fence Yes No
Above Ground Yes No
Diving Board Yes No

Protection Device Type
Central

Direct
Local

Distance to Fire Hydrant ft. Distance to Fire Station miles

Central Heating Occupied Daily
Visible to Neighbors Smoke Detector
Fire Extinguisher Within City Limits?
Deadbolts In Fire District
Sprinkler
Roof Type

 

GENERAL INFORMATION

Please Answer the following:
Any business conducted on premises? (including day/child care)
Has applicant had a foreclosure, repossession or bankruptcy during the past 5 years?
Any supplemental heating?
Any flooding, brush hazard landslide, etc?
Does applicant own any recreational vehicles?
Is property situated on more than 5 acres?
Does applicant or any tenant have any animals or exotic pets?
Is property situated on more than 5 acres?
Any other residence owned, occupied or rented?

 

LOSS INFORMATION

Date Type Description of Loss Amount

 

REPLACEMENT COST INFORMATION

# Stories Ground Floor Area SQ FT
Exterior Wall Material Construction Type

Slab SQ FT
Basement SQ FT

Finished Attic SQ FT $
Porch Type SQ FT $
Balcony/Deck SQ FT $
Extra Baths SQ FT $
Finished Basement/Recroom SQ FT $
Breezeway SQ FT $
Screen Patio SQ FT $

Fireplace $
Air Conditioning $
Roof Type $
Garage Type $

Flood Coverage? (Not Covered unless you select coverage)
Do you currently have homeowners insurance?
Who is your current homeowners insurance company?
When does your current policy expire?

 

PRIOR POLICY/LOSS HISTORY

Previous Carrier
Policy Number
Exp. Date
# Losses Last 3 Yrs
Total Losses $