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