Home Owners/Renters Quote:
Contact Information
Name
Street Address
Current Mailing Address
City, State, Zip
Email Address
Date of Birth
Occupation
Employer
How long with current Employer
Home Phone
Work Phone
Cell Phone
Home Owners or Renters
No Preference
HomeOwners
Renters
Spouse Information
Spouse Name
Date of birth
Occupation
Employer
Work Phone
Home To Be Insured
Street Address
City, State, Zip
How long at present address
Previous home address
(if less than 3 years
at present address)
If Mobile Home
a. Do you own or rent the land
Select One
Own
Rent
b. Is mobile home in a park?
Select One
Yes
No
Park Name
c. Mobile home Width & Length
d. Manufacturer Name
e. Model Name
f. Year Built
g. Serial Number
Rating Information
1. What year was this home built?
2. What type of construction was used?
Select One
Frame
Masonry
Aluminum Siding
3. Number of Families
Select One
1
2
3
4
5
4. Other Occupancies
5. Age of Roof
6. Roof Type
Select One
Composition
Metal
Other
If Other
7. What style is your home?
Select One
Sgl Family Dwelling
Apartment Building
Condominium
8. How will your home be used?
Select One
Primary Residence
Secondary Residence
Seasonal Home
9. How far to the nearest fire station?
miles
10. How far to the nearest hydrant?
feet
11. Distance to coast?
miles / feet
12. Is home rented to others?
Select One
Yes
No
If Yes, how many weeks?
13. How many total living square
feet on the first floor?
14. Do you have a woodstove?
Select One
Yes
No
If yes, please describe type and use
15. Any smokers in household?
Select One
Yes
No
16. What is your primary source of heat?
If oil, tank location
17. What is your secondary source of heat?
Protective Devices
18. Do you have a security system?
Select One
Yes
No
If yes, please describe what type
Burglar Alarm
Select One
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Select One
Yes
No
Smoke Detectors
Select One
Yes
No
19. Have you had any losses in the past 8 years?
Select One
Yes
No
If yes, please describe
20. Is this your first home?
Select One
Yes
No
If no, do you have current insurance?
Select One
Yes
No
21. Do you have any pets?
Select One
Yes
No
If yes, please describe
Any bite history?
22. Any Hot Tub, Sauna, Swimming Pool, Trampoline,
Wet Bar, Etc.?
Select One
Yes
No
If yes, please describe
23. Any updates that have been done on home
(i.e., new roof, electrical, heating, retrofitting, etc).
Select One
Yes
No
If yes, please enter date complete and describe
If the building is over 25 years old, please answer the following:
24. Year Electricity was Updated
25. Is it on Circuit Breakers
Select One
Yes
No
Number of Amps?
26. Year Plumbing was Updated
27. Type of Plumbing
Select One
Copper
Galvanized
PVC
Other
If Other
28. Any business conducted on premises? If so, what type?
Current Insurance
1. Previous Carrier
2. Policy Dates
Start Date
End Date
3. How Long Insured
4. Amount insured for
5. Policy Number
6. Prior Premium
7. Policy Renewal Date
8. Any bankruptcy in the past? When?
Coverage Information
1. Dwelling
2. Contents
3. Liability
4. Medical Payments
5. Deductibles
All Perils
Wind/Hail/Storm
Please use the space below to add comments regarding any special circumstances or coverage needs
Agent Preference
No Preference
Christopher Meister
Rick Prather
Missy Fischer
Charles Prather
Tom Kummer