HOMEOWNER QUOTE

No coverage is bound until you are contacted by one of our representatives

CONTACT INFORMATION

Name

Street Address

Street Address 2

City

State

Zip

Social Security #

Date of birth

Contact Info

Home

Work

Email Address

HOME LOCATION

Street Address

Street Address 2

City

State

Zipcode

RATING INFORMATION

1. What year was this home built?

2. What type of construction was used?

3. What style is your home?

4. How will your home be used?

5. How many rooms in your home?

6. How many full bathrooms in your home?

7. How many 3/4 bathrooms in your home?

8. How many 1/2 bathrooms in your home?

9. How many square feet on the first floor?

10. What type of home do you have?

11. How many total square feet in your home?

12. Do you have a fireplace?

If yes, please describe what type

13. Do you have a woodstove?

If yes, please describe type and use

14. Do you have a garage?

If yes, please describe what type

15. What is your primary source of heat?

16. What is your secondary source of heat?

17. Do you have a security system?

If yes, please describe what type

18. Have you had any losses in the past 3 years?

If yes, please describe

19. Is this your first home?

If no, do you have current insurance?

If yes, Please describe

21. Any hot tub, swimming pool, sauna etc?

If yes, Please describe

22. Any updates that have been done on home,
(i.e., new roof, electrical, heating, retrofitting, etc).

If yes, Please enter date complete and describe

COVERAGE INFORMATION

1. Do you want earthquake coverage?

2. Do you have collections worth over $500?

If yes, Please describe

3. Do you have any single piece of jewelry valued over $500?

If yes, Please describe

4. Do you have work tools that need coverage?

If yes, Please describe

5. Do you operate a business out of your home?

If yes, Please describe