Property Quote Kindly complete this form and submit so we can prepare your home / landlord / vacant dwelling / mobile home insurance quote. General Information Name: * Mailing Address: City: State: Zip: Day Phone: Evening Phone: Best time to contact: AMPM E-mail address: * Occupation: Date of Birth: Current Insurance Section Company: (Not Agency, If no current insurance mark "none") Policy Expiration Date: (xx/xx/xxxx) Annual Premium: Property Information Section Property Location Address: City: State: Zip: Years Constructed: Square Footage: Approximate market value of dwelling: Property Style: ---Single Family DetachedTwin HomeRow HomeTown HomeMulti Family DwellingCondoMobile Home Construction Material: ---Frame (Vinyl / Aluminum / Wood Siding)StuccoBrickStone Number of Families: ---1234 Occupancy of Property: Primary HomeSecond / Vacation HomeRental PropertyVacant Property Number of stories: ---123Bi-levelTri-level Is there a basement: YesNo Is the Basement Finished Living area: FinishedUnfinished Other Features (Check all that apply): Dead Bolts on Doors Smoke Detectors Fire Extinguishers Sprinklers Central Burglar Alarm Central Fire Alarm Solar Panels or Geothermal Heating/Energy Within 5 miles of Fire Dept. Within 1000 Feet of Fire Hydrant Wood / Coal / Pellet Stove Underground Oil Tank Tree House Jungle Gym / Swing Set Pond/Lake/Stream/River or other body of water Outdoor Hot Tub Swimming Pool Is Pool Completely Fenced with Locking Gate: YesNo Does Pool have a Siding Board: YesNo Does Pool have a Diving Board: YesNo Type of Pool: Above GroundIn Ground Trampoline Is it Netted: YesNo Home in a development: YesNo Property Update Section Roof Type of Roof: ---PeakedFlat Roof Materials: ---Roll RoofRubberAsphalt ShingleMetalSlateTerra Cotta Year Roof was last replaced: Heating Type of Heating System: ---OilNatural GasPropaneElectricCoalWood Year Heating system was last replaced: Is there a secondary heat source: YesNo If Yes, Type: ---Wood StoveCoal StovePellet StoveFireplace Electrical Type of Electrical Panel: ---Circuit BreakerFuses Type of Wiring: ---RomexKnob & Tube Number of AMP: ---Less than 100 amp100 amp200 amp Year electrical was last updated: Plumbing Year water heater was last replaced: Year plumbing was last updated: Coverage Section Dwelling Amount: Other Structures: Personal Property: Loss of Use / Rents / Additional Living: Personal / Premises Liability: ---100,000200,000300,000400,000500,000 Medical Payments: ---1,0002,0003,0004,0005,000 Deductible: ---250500750100015002500 Additional Coverage: (Select all the ones you desire) Replacement cost on contents Replacement cost on Dwelling Sinkhole coverage Earthquake coverage Water Backup coverage Umbrella / Excess liability coverage Identity fraud coverage Special coverage for jewelry, fine arts, antiques, guns etc. Flood In home business coverage Additional Questions and Comments In order to provide you with an accurate quote the company will obtain your credit insurance score and additional reports to verify the driving records and claims history for the person / persons applying for the insurance. This will not have an effect on your credit history. * I have read the Information Disclosure and accept the above terms and conditions
