|
HOMEOWNERS INSURANCE QUOTE REQUEST |
|
Personal Information |
| What
is your name? |
Last
|
|
|
First
|
|
|
Middle
|
|
| What
is your mailing address? |
Street
|
|
|
City
|
|
|
State
|
|
|
Zip
|
|
| What
is your telephone number? |
Home
|
|
|
Work
|
|
| What is your
fax number? |
Fax
|
|
| What is your
email address? |
Email
|
|
What is your
date of birth
(for discount purposes)? |
Date of Birth
|
|
| How would you
rate your credit? |
Credit
|
|
|
Property Information |
| What
is the property address? |
Street
|
|
|
City
|
|
|
State
|
|
|
Zip
|
|
| What is your
mortgage balance? |
Mortagage Balance
|
|
| What is the
market value of your home? |
Market Value
|
|
| Number of families? |
#Families
|
|
| What is the dwelling
type? |
Dwelling Type
|
|
| How many bedrooms
are there? |
Number of Bedrooms
|
|
| How many bathrooms
are there? |
Number of Full Bathrooms
|
|
| |
Number of Half Bathrooms
|
|
| How many fireplaces
are there? |
Number of Fireplaces
|
|
| How many porches
or decks are there? |
Porches or Decks
|
|
| |
Square Footage of Porch/Deck
|
|
| What year was
it built? |
Year Built
|
|
| What date was
the property purchased? |
Purchase Date
|
|
| What is the
construction type? |
Construction Type
|
|
| How
many stories? |
Stories
|
|
| If two stories,
what is the ground floor square footage? |
Ground Floor Square Footage
|
|
| What is the
total square footage of the building? |
Total Square Footage
|
|
| What
is the property's topography? |
Property's Topography
|
|
| What foundation
type? |
|
| If structure
is located in a flood zone, what is the distance to body of water? |
|
| What type of
garage? |
|
| What type roof
covering? |
|
| Was the roof
updated? |
Updated Roof
|
Yes
No |
| If yes, what
year? |
Year Roof Updated
|
|
| Does the building
have a pool? |
Pool
|
Yes
No |
| If there is
a pool, is it fenced? |
Pool Fence
|
Yes
No |
| If there is
a pool, is there a lockable fence? |
Lockable Fence
|
Yes
No |
| If there is
a pool, is there a diving board? |
Pool Diving Board
|
Yes
No |
| If there is
a pool, is there a slide? |
Pool Slide
|
Yes
No |
|
What is the distance of fire protection?
|
|
|
| Is the building
in the brush? |
Brush
|
Yes
No |
| Is there a brush
hazard within one mile of the building? |
Brush Within 1 Mile
|
Yes
No |
| If yes, has
the brush been cleared by 250 feet from all sides of the building? |
Brush Cleared by 250 Feet
|
Yes
No |
| Is there a smoke
alarm? |
Smoke Alarm
|
Yes
No |
| Is there a fire
extinguisher? |
Fire Extinguisher
|
Yes
No |
| Are there deadbolts? |
Deadbolts
|
Yes
No |
| Is the electrical
updated? |
Electrical Update
|
|
| Are there circuit
breakers? |
Circuit Breakers
|
Yes
No |
| Does the electrical
circuit box have copper wiring? |
Copper Wiring
|
Yes
No |
| Do you have
central air? |
Central Air
|
Yes
No |
| How old is the
heating/ air conditioning? |
Age Heating/ Air Conditioning
|
|
| Is the heating/
air conditioning thermostatically controlled? |
Thermostatically Controlled
|
Yes
No |
| What is the
energy source? |
Energy Source
|
|
| What is the
heating system? |
Heating System
|
|
| What is the
cooling system? |
Cooling System
|
|
| Has the plumbing
been updated? |
Plumbing Updated
|
Yes
No |
| Is the plumbing
copper? |
Copper
|
Yes
No |
| Does the building
have interior automatic fire sprinklers? |
Automatic Fire Sprinklers
|
Yes
No |
| Is there a theft
alarm? |
Theft Alarm
|
Yes
No |
| Is there a fire
alarm? |
Fire Alarm
|
Yes
No |
| Are the alarms
Monitored? |
Monitored Alarms
|
Yes
No |
| What is the
earthquake zone? |
Earthquake Zone
|
|
| Has it been
earthquake retrofitted? |
|
| What is the
fire district? |
Fire District
|
|
| Do you have
a trampoline? |
Trampoline
|
Yes
No |
| Number of acres
dwelling is located on |
Number of acres
|
|
| Are there dogs
on the property? |
Dogs on Property
|
Yes
No |
| If yes, how
many and what is the breed of each dog? |
|
| Are there any
other pets or animals on the property? |
Pets or Animals
|
Yes
No |
| If
yes, how many and what is the description of each? |
|
|
Current Coverage Information |
| What is the current insurance
company? |
|
| What is the expiration date of
current policy? |
Expiration Date
|
.
|
| Where there any losses or claims
in the last 5 years? |
Losses - Claims
|
Yes
No |
| If yes, what is the date, amount
paid and description of each loss or claim? |
|
|
Desired Coverage Information |
| Dwelling Amount |
Coverage A
|
|
| Other Structures |
Coverage B
|
|
| Personal Property |
Coverage C
|
|
| Loss of Use |
Coverage D
|
|
| Premise Liability |
Coverage E
|
|
| Policy Deductible |
Amount
|
|
| If earthquake insurance is requested,
select deductible percentage % |
Earthquake Deductible
|
|
| Do
you want building replacement cost coverage? |
Yes
No |
| Do
you want contents replacement cost coverage? |
Yes
No |
| Questions or Comments |
|
|
|
