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HOME OWNER'S INSURANCE QUOTE FORM

Personal Information

Name:

Street:

City:

State:

Zip:

Home Phone:

Phone 2 (If different):

Email Address:

Property Information

Owned/Rented:

Owned Rented

Street Address:

City:

State:

Zip:

Occupied by Owner:

Yes No

If the property is owned:

Primary Secondary

Limited Access Community (Gated):

Yes No

24-hour/community patrolled:

Yes No

Construction Type:

Year Built:

Square Footage/Foundation Area

square feet

# of Families:

# of Stories

Replacement Cost:

Current Dwelling Coverage (Coverage A) on Property:

Current Liability Limit:

Medical Payments:

Current Deductible:

Distance to Hydrant:

feet

Distance to Fire Station:

miles

Custom Built:

Yes No

Basement Type:

% Full % Crawl Space % Slab

Bankruptcy in the last 5 years:

Yes No

Currently Insured:

Yes No
If yes, current insurance carrier:

Under construction/renovation:

Yes No
If yes, date of completion:

Central Air:

Walk Out Basement:

Yes No

Finished Basement:

Yes No

Wood Foundation:

Yes No

Fireplace:

Yes No

# Full Baths:

# Half Baths:

Deck:

Yes No
If yes, size: square feet

Porch:

Yes No
If yes, size: square feet

Attached Garage:

Yes No
If yes, describe:

Rooms Above Garage:

Yes No
If yes, dimensions/size:

Breezeway:

Yes No

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Additional Items (Fine Arts, Collectibles, Jewelry, etc. with Appraisals):

Total Personal Property Value:

# Apartments:

Structure Type:

Resident Smoker(s):

Yes No

Purchase Date (MM/DD/YYYY):

Purchase Price:

Claims (Date, Description, Amt. Paid)

Fire Alarm (Direct to station):

Yes No

Burglar Alarm:

Yes No

Fuel:

Gas
Oil --> Storage tank location:

Electric
Wood
Coal
Solar

Most recent year of renovation:

Electrical:

Plumbing:

Heating:

Roof:

Exterior Painted:

Electrical:

Service:

Circuit Breakers Fuses

Amperage:

Any owner over 65:

Yes No

Check security devices that apply:

Deadbolt
Smoke Detector
Fire Extinguisher
Security Alarm

Swimming Pool:

Yes No

Diving Board

Approved Fence

Above Ground

In Ground

Screened Pool Enclosures:

Yes No

Storm Shutters:

Yes No

Sprinkler System:

Yes No

Construction Class:

Unfinished Level:

Yes No

Finished Attic:

Yes No

Roof Type:

General Information

Please check all that apply:

Trampoline on Premises

At-Home Business

Description:

Present hazard of flooding, brush fire, forest fire, or landslide

Description:

Dog(s)

Specific Breeds:

Property located on more than five acres

Description:

Property located within two miles of tidal water

Description:

Response Method

I would like my quote sent to me via:

Phone (If different from home):

Fax Number:

Thank You!
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