Your information will be used for insurance quoting purposes only.


Contact Information

First and Last Name

Phone Number

Email address

Mailing address

Insured location address (if different than mailing address)

Date of Birth

Home Information

Dwelling is a ---Single Family HomeDuplexTriplexQuadplexCondoTownhomeMobile HomeManufacture Home

Dwelling Status ---Owner Occupied Primary HomeOwner Occupied Secondary HomeRented to Tenants

Any Home insurance claims in the last five years

What year was your home built

Except for a garage area, the home is built over a ---BasementWalkout BasementCrawlspaceSlabBasement & CrawlspaceBasement & SlabCrawlspace & Slab

Not including a basement, the home is ---1 story2 storyBi-levelTri-level

Basement Square Footage (if applicable)

Home’s total square feet (not including the basement)

Number of full bathrooms (include sink, toilet & Tub)

Number of ¾ bathrooms (include a sink, toilet & shower)

Number of ½ bathrooms (Sink and toilet only)

Approximately how old is the roofing

Roofing material is ---Three Tab AsphaltNewer Dimensional AsphaltT-Lock AsphaltWoodConcreteClaySteelMetalGravelNot sureOther

Number of insurance claims in the past 5 years ---No claimsOne (1) claimTwo (2) claimsThree (3) or more claims

Discounts

Is there a mortgage on Home (for no-mortgage discount) YesNo

Does this home have hail resistive shingles on the roof YesNoUncertain

Does the home have sprinklers in the celling for fire suppression YesNo

Does this home have a burglar alarm YesNo

Coverage

Dwelling ($)

Personal Property (if known) ($)

Loss of use (if known) ($)

Liability ---$100,000$300,000$500,000

Medical Payments ---$1,000$2,000$5,000

Deductible ---$1,000$1,500$2,500$5,000

Extras (Optional)
(Completing this information will result in a more accurate dwelling coverage and insurance quote)

Garage Type ---No garageAttached garageBasement garageDetached garageCarport

# Car garage (if applicable) ---1234 or moreNo garage

Air Conditioning ---NoneCentral air using heating ductsCentral air using separate ductsSwamp cooler

Exterior Walls ---Hardboard sidingBrick on frameSolid brick/blockWood sidingStoneLog-handcraftedLog-manufacturedLog-sidingConcrete

The home’s central heating is ---Gas forced airGas hot waterElectricRadiant FloorFireplaceOther

Fireplace type ---No fireplaceGasWood burningWood stovePellet stove

Fireplace #2 type ---No extra fireplaceGasWood burningWood stovePellet stove

Fireplace #3 type ---No extra fireplaceGasWood burningWood stovePellet stove

Total decks and/or balcony square feet (if applicable)

Decks and balcony material (if applicable) ---No decksWoodRedwoodComposite

Total sq. ft. of the covered patios and/or porches

Mark all the features this home has:
Sliding glass doorsExterior french doorsBay or bow windowsSkylightIndoor hot tubSolar panelsWheelchair lift systemElevatorIndoor Sauna