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HOMEOWNERS INSURANCE QUOTE REQUEST

Personal Information

What is your name?

Last:

First:

Middle:

What is your mailing address?

Street:

City:

State:

Zip:

What is your telephone number?

Home:

Work:

What is your fax number?

Fax:

What is your email address?

Email:

What is your date of birth?

Date of Birth:

How would you rate your credit?

Credit:

Property Information

What is the property address?

Street:

City:

State:

Zip:

What year was this home built?

Year Built:

What was the purchase price of this home?

Purchase Price:

Number of families?

Number:

What is the dwelling type?

Type:

How many bedrooms are there?

Number of Bedrooms

How many bathrooms are there?

Full Bathrooms:

Half Bathrooms:

How many fireplaces are there?

Fireplaces:

How many porches or decks are there?

Porches or Decks:

Square Footage:

What year was it built?

Year Built:

What date was the property purchased?

Purchase Date:

What is the construction type?

Type:

How many stories?

Stories:

If two stories, what is the ground floor square footage?

Square Footage:

What is the total square footage of the building?

Square Footage:

What is the property's topography?

Topography:

What foundation type?

Type:

If structure is located in a flood zone, what is the distance to body of water?

Distance:

What type of garage?

Type:

What type roof covering?

Type:

Was the roof updated?

Yes No

If yes, what year?

Year Roof Updated:

Does the building have a pool?

Yes No

If there is a pool, is it fenced?

Yes No

If there is a pool, is there a lockable fence?

Yes No

If there is a pool, is there a diving board?

Yes No

If there is a pool, is there a slide?

Yes No

What is the distance of fire protection?

Is the building in the brush?

Yes No

Is there a brush hazard within one mile of the building?

Yes No

If yes, has the brush been cleared by 250 feet from all sides of the building?

Yes No

Is there a smoke alarm?

Yes No

Is there a fire extinguisher?

Yes No

Are there deadbolts?

Yes No

Is the electrical updated?

Are there circuit breakers?

Yes No

Does the electrical circuit box have copper wiring?

Yes No

Do you have central air?

Yes No

How old is the heating/ air conditioning?

Age Heating/ Air:

Is the heating/air conditioning thermostatically controlled?

Yes No

What is the energy source?

Energy Source:

What is the heating system?

Heating System:

What is the cooling system?

Cooling System:

Has the plumbing been updated?

Yes No

Is the plumbing copper?

Yes No

Does the building have interior automatic fire sprinklers?

Yes No

Is there a theft alarm?

Yes No

Is there a fire alarm?

Yes No

Are the alarms monitored?

Yes No

What is the earthquake zone?

Earthquake Zone:

Has it been earthquake retrofitted?

What is the fire district?

Fire District:

Do you have Trampoline?

Yes No

Number of acres dwelling is located on

Number of acres:

Are there dogs on the property?

Yes No

If yes, how many and what is the breed of each dog?

Are there any pets or animals

Yes No

If yes, how many and what is the description of each?

Current Coverage Information

What is the current insurance company?

What is the expiration date of current policy?

Expiration Date:

Where there any losses or claims in the last 5 years?

Losses - Claims: Yes No

If yes, what is the date, amount paid and description of each loss or claim?

Desired Coverage Information

Dwelling Amount

Coverage A:

Other Structures

Coverage B:

Personal Property

Coverage C:

Loss of Use

Coverage D:

Premise Liability

Coverage E:

Policy Deductible

Amount:

If earthquake insurance is requested, select deductible percentage %

Do you want building replacement cost coverage?

Yes No

Do you want contents replacement cost coverage?

Yes No

Questions or Comments