Choose The Reason You Require
Homeowners Insurance:
New Purchase
Policy Canceled
Re-Finance
Policy Lapsed
Paying Too Much
How many
claims have you made in the last 5 years?(give claim details and dates in
section)
Current Insurance Company (if
none, please type none)
Policy Expiration Date
Type of
Home
One Family
Two Family
Three Family
Four or More
Occupancy:(check all that apply)
Owner Occupied
Rented to Others
Second Home
Owner &
Tenant
Specific Information on the Home
Construction of Home
Wood Frame/Vinyl or
Aluminum siding
Brick/Masonry
Concrete
Style of Home
Number of Stories
(excluding basement)
Approximate living area in
square feet
(excluding basement)
What year was the home built?
Approximate if unsure.
(ex.1968)
What type of Foundation supports
the home
Concrete Slab
Crawl Space
Basement(finished)
Basement (unfinished)
Pilings
Roofing Material
Asphalt or Architectural
Shingles
Clay or Spanish Tile
Slate
Wood Shake (very old homes)
Roofing shingles last
replaced
(enter year, original, or unsure)
Type of Heating
Oil or Gas Burner replaced or updated
(enter year, original, or unsure)
If oil heat, where is the tank?
Buried in ground
Above ground
In crawl space or
basement
Electrical System
How many amps in
electrical service
(60,100,150,200)
Does your
electrical system
have circuit breakers?
Yes No
Electrical
System Upgraded
(enter year, original, or unsure)
Garage Type
# of cars garage holds
Security
Features (check all that
apply)
Smoke Detectors
Fire Extinguishers
Dead Bolts
Local
Burglar Alarm(rings outside home)
Local Fire
Alarm (rings outside home)
Central Station
Burglar Alarm
Central Station Fire
Alarm (Central station means connected directly to a monitoring facility that contacts
police or fire dept on your behalf)
Home Features
Central Air
Number of Bathrooms
# Fireplaces
Wood Stove
Yes No
Swimming Pool
If
yes, Diving Bd.
Yes No
If
yes, fenced in
Yes No
Insurance Coverages
Insurance Coverages
What is the purchase price of the dwelling?
$
Mortgage Amount
$
Dwelling Amount
Personal Property Cov.
Personal Liability Cov
Building Deductible
Is
Flood Coverage Required?
Yes No
If
Flood is requested, how much
coverage is needed?
Flood
deductible
Do you need coverage for scheduled personal
property (jewels, furs, silver) beyond what the standard policy offers? Usually big ticket
items.
Yes No
If yes, give amt in $'s for each
example $12,000
Jewelry $
Furs $
Silver $
Other
Underwriting Questions
Underwriting questions (as
you may know, credit has become a major factor in obtaining insurance in a number of
states, so please be aware that where applicable, rates will be quoted based on your
responses below)
