Home/Mobile home Owner Quote
No coverage is bound until you are contacted by one of our representatives
CONTACT INFORMATION
Name
Street Address
Current Mailing Address
City, State, Zip
Email Address
Social Security #
Date of birth
Occupation
Employer
How long with current Employer
Phone Number
Home
Work
SPOUSE INFORMATION
Social Security #
Date of birth
Occupation
Employer
Phone Number
Work
HOME TO BE INSURED
Street Address
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
If yes, 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 Stories
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
Farm
Unoccupied
Vacant
9. How many rooms in your home?
10. How many full bathrooms in your home?
11. How many 3/4 bathrooms in your home?
12. How many 1/2 bathrooms in your home?
13. How many square feet on the first floor?
14. What type of home do you have?
Select One
Single story
Two story
Split entry
Tri-Level
15. How many
total
square feet in your home?
16. Do you have a fireplace?
Select One
Yes
No
If yes, please describe what type
17. Do you have a woodstove?
Select One
Yes
No
If yes, please describe type and use
18. Do you have a garage?
Select One
Yes
No
If yes, please describe what type
Select One
Attached single car
Attached two car
Attached three car
Detached single car
Detached two car
Detached three car
Carport
19. What is your primary source of heat?
20. What is your secondary source of heat?
PROTECTIVE DEVICES:
21. Do you have a security system?
Select One
Yes
No
If yes, please describe what type
Burgler Alarm
Select One
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Select One
Yes
No
Smoke Detectors
Select One
Yes
No
22. Have you had any losses in the past 3 years?
Select One
Yes
No
If yes, please describe
23. Is this your first home?
Select One
Yes
No
If no, do you have current insurance?
Select One
Yes
No
24. Do you own any pets?
Select One
Yes
No
If yes, Please describe
25. Any Hot Tub, Sauna, Swimming Pool, Trampoline, wet Bar, Etc.?
Select One
Yes
No
If yes, Please describe
26. 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:
27. Year Electricity was Updated
28. Is it on Circuit Breakers
Select One
Yes
No
29. Year Plumbiing was Updated
30. Copper or Galvanized Plumbing
Select One
Copper
Galvanized
Other
If Other
CURRENT INSURANCE
1. Previous Carrier
2. Start date
End Date
3. How Long Insured
4. Amount insured for
5. Policy Number
6. Prior Premium
$
7. Policy Renewal Date
COVERAGE INFORMATION
1. Dwelling
2. Contents
3. Liability
4. Medical Coverage
5. Deductibles
All Perils
Wind/Hail/Storm
6. Loss of Use
ADDITIONAL INSURED
Name
Address
Phone Number
Phone
FAX
Account or Loan #
LIEN HOLDER
Name
Address
Phone #
Fax #
Loan #
Mortgage Clause
Legal description
Please use the space below to add comments regarding any special circumstances or coverage needs