Personal Information
First Name:
Middle Initial:
Last Name:
Daytime Phone:
Evening Phone:
Cellular Phone:
Preferred Method of Contact:
Daytime Phone
Evening Phone
Cellular Phone
Email
Date of Birth:
Social Security:
Employer Name:
Occupation:
How Long:
Less than 1 year
1 - 3 years
4 - 5 years
5 - 10 years
10 - 20 years
20+ years
Email Address:
Marital Status:
Single
Married
Divorced
Widowed
Spouse Information
First Name:
Middle Initial:
Last Name:
Date of Birth:
Social Security:
Work Phone:
Employer Name:
Occupation:
How Long:
Less than 1 year
1 - 3 years
4 - 5 years
5 - 10 years
10 - 20 years
20+ years
Home Address:
City:
State:
Zipcode:
How Long at Current Address?
1 year
2 years
3+ years
Previous Address:
City:
State:
Zipcode:
Mortgaged:
Yes
No
Mortgage Information
Loan Number:
Mortgage Company:
Address:
City:
State:
Zipcode:
Escrow:
Yes
No
Check if purchasing a new or used home.
If new home, what was the purchase price?
$
Title Company Name:
Address:
Contact:
Phone:
Construction of Home
Construction:
Brick
Brick Veneer
Frame
Log
Foundation:
Slab
Pier & Beam
Wooden Blocks
Other
Number of Stories:
1
2
3
3+
Roof Material:
Wood
Composition
Tile
Metal
Age of Roof:
1-3 years
4-6 years
7-10 years
11-15 years
15+ years
Ground Floor Sq. Footage:
Year Built:
Check here if house was built prior to 1950
Thermostatic Controlled Heat:
Yes
No
Updates:
Electrical
Plumbing
Electrical Updates
Year of Updates:
Extent of Updates:
Full Update
Partial Update
Plumbing Updates
Year of Updates:
Extent of Updates:
Full Update
Partial Update
Home Features
1. Garage?
Yes
No
Capacity:
1 car
2 car
3 car
4 car
5 car
5+ car
Type:
Attached
Detached
2. Carport?
Yes
No
Capacity:
1 car
2 car
3. Number of Bathrooms.
Full Baths:
1
2
3
4
5
5+
Half Baths:
0
1
2
3
4
5
5+
4. Fire Place:
0
1
2
3
4
5
5+
5. Central Heat:
Yes
No
Central Air:
Yes
No
Age of System:
1 year
2 year
3 year
4 year
5 year
5+ year
6. Central Vacuum System:
Yes
No
7. Domestic Solar Water Heater:
Yes
No
8. Hot Tub (Not whirlpool tub), Swimming Pool, or Sauna:
Yes
No
9. Interior Sprinkler System:
Yes
No
10. Pre-fabricated Fireplace insert:
Yes
No
11. Built-In Refrigerator:
Yes
No
12. Wooden Decks:
Yes
No
Square Footage:
13. Breezway:
Yes
No
Square Footage:
14. Patio:
Yes
No
Square Footage:
15. Porches:
Yes
No
Square Footage:
17. Security & Fire Alarm Monitored by Central Station:
Yes
No
Company:
18. Video Door-Answering System:
Yes
No
19. Animals?
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Yes
No
Type and Breed:
20. Is property in a Flood Zone?
Yes
No
Classification Survey
Does the residence have any of the following? (check all that apply)
Den (Not converted Bedroom)
Family Room (In addition to Living Room)
Large Foyer (over 70 sq. ft.)
Library
Recreation Room
Sunroom
Great Room (Greater than 300 ft.)
Exercise Room
Formal Dining Room
Laundry Room
Office
Study
Grand Room (Above 2 Stories)
General Shape of Residence
Basic Box Shape
"L" Shaped
Irregular Shape
Very Irregular Shape
Special Features
Any bedrooms which adjoin a bathroom or sitting room?
Any woodburning masonry fireplaces?
Brick or stone exterior walls (over 50%)?
Any hardwood, slate, marble or quarry tile floors?
Stained or varnished woodwork?
Survey Score:
Desired Coverage
Section I - Property
Section II - Liability
Coverage A - Dwelling:
Coverage C-P/Liability:
300,000
500,000
Coverage B - Contents:
Coverage D-M/Payments:
1000
5000
10,000
Do You Have any Silverware, Fine Arts, Jewelry, or Guns
Yes
No
Valuables
Silverware
Amount:
$0-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000+
Fine Arts
Amount:
$0-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000+
Jewelery
Amount:
$0-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000+
Guns
Amount:
$0-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000+
How many losses have occurred during the last 3 years to the insured's home or personal possessions at this or another location?
none
1
2
3
4
Cause of Claim 1:
Fire Claim
Hail
Lightning
Theft
Water Claim
Water Damage
Cause of Claim 2:
Fire Claim
Hail
Lightning
Theft
Water Claim
Water Damage
Cause of Claim 3:
Fire Claim
Hail
Lightning
Theft
Water Claim
Water Damage
Cause of Claim 4:
Fire Claim
Hail
Lightning
Theft
Water Claim
Water Damage
Additional comments or information that might be helpful to your quote:
