Homeowners Insurance Quote
General Information
Name:
Address:
City:
State:
ZIP:
County:
Twp or Borough:
Phone Day:
-
Night:
-
Best time to call:
am
pm
E-mail:
Fax:
-
Occupation:
How long at current job:
years
months
Spouses Occupation:
How long at current job:
years
months
How would you like to be contacted?
Telephone
E-mail
Fax
Current Homeowners Insurance Company
(not agency)
:
Company Name:
Policy Exp. Date:
/
/
Annual Premium:
$
# of Claims in 5 years:
Total paid on these claims:
$
Short Description of Claims:
Home Information
How long at present address:
years
months
If own a dog(s), list dominant breed(s)
Distance to Fire Hydrant:
feet
Miles to Fire Dept:
Are you visible from 10 surrounding houses?
yes
no
Year home was built:
If home more than 20 years old:
Year roof updated:
Year central heating updated:
What type electical service:
Circuit Breakers
Fuses
Safety Equipment:
Smoke Detector
yes
no
Dead Bolt Locks
yes
no
Fire Extinguisher
yes
no
Security System
yes
no
Frame
Brick
Insurance Coverages
Dwelling Amount
$
Contents Amount
$
Liability Amount
$
Optional Coverages
Scheduled Jewelry
$
Other Scheduled Items(computer/guns/bike)
$
Sewer & Drain
yes
no
Personal Liability (Umbrella)
yes
no
Other
I would like more information on annuities/retirement planning
yes
no
I would like more information on life insurance
yes
no
Additional Comments:
Please give any additional comments you desire:
