INSURANCE   


                                    HOME OWNERS INSURANCE
         1.Contact    
NAME, ADDRESS AND CONTACT INFORMATION
Fields marked (*) are mandatory.  
First Name*
Last Name*
Home Phone* ( ) - -
Work Phone ( ) - - Ext:
E-mail*
Reffered By
SSN #
Rate your credit

        2. Property General    
PRIOR INSURANCE
Fields marked (*) are mandatory.  
Have prior insurance:
If Other Insurer is selected Enter Insurer Name
Have Insurance with them for*
Estimated Yearly Premium (in US$)
Prior Policy Ends On* YYYY

        3.Property General    
PROPERTY GENERAL
Fields marked (*) are mandatory.  
Address 1*
City*
State*
Zip Code*
Property Surroundings*
Distance to Fire Station*
Distance to Hydrant(ft)*Under 1000Over 1000
Year Built*
Property Use*
Square Footage*
Number of Families*
Number of Stories*
Dog Type*

         3.Property General
PROPERTY VALUES
Fields marked (*) are mandatory.  
Purchase Date* YYYY
Purchase Price*
Est. Current Market Value*
Est. Replacement Value*

         4.Property Details
CONSTRUCTION DETAILS
Fields marked (*) are mandatory.  
Construction Type*
Roofing Material*
Age of Roof
Electrical Type*
Heat Type*
Number of Fireplaces*
Number of Bathrooms*

         5.Property Details
PROTECTION DEVICES
Fields marked (*) are mandatory.  
Burglar Alarm*
Fire Alarm*
Smoke Detectors*
Fire Extinguishers on Each FloorYesNoNot sure
Fire Sprinkler System*

         6.Property Details
BUILDING DETAILS
Fields marked (*) are mandatory.  
Number of Basements*
Basement Sq. Footage(est.)
Basement Finished Percentage(est.)
Garage Type*
Garage Sq. Footage (est.)

         7.Property Details
OTHER STRUCTURES
Fields marked (*) are mandatory.  
Swiming Pool Type*
Swiming Pool Fence Construction Type
Has Diving BoardYesNo

        8.Application    
ADDITIONAL INFORMATION
Fields marked (*) are mandatory.  
 The questions bellow will help the Insurers to determine the best discounts to be awarded
Have you had any reported losses during the past 3 years?*YesNo
Any business conducted on premises? (including day/child care)*YesNo
Any residence employees?*YesNo
Has application had a foreclosure, repossession or bankruptcy during the past five years?*YesNo
Does applicant own any recreational vehicles (snowmobiles, dune buggies, mini bikes, ATVs, etc.)?*YesNo
Is building retrofitted for earthquake?*YesNoNot sure

         9.Coverages   
BASIC COVERAGES
Fields marked (*) are Mandatory Coverages.  
COVERAGE NAME LIMITS                            %BASE
Dwelling
Other Structures*  
Personal Property*  
Loss of Use*  
Personal Liability*
Medical payments*
DEDUCTIBLES
All Perils Deductible*
CREDITS
Non-Smoking Household YesNo
 

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