HOMEOWNERS INSURANCE QUOTE REQUEST
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| Personal
Information |
| What is your name? |
*Last |
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*First |
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*Middle |
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| What is your mailing address? |
Street |
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City |
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State |
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Zip |
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| What is your telephone number? |
Home |
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Work |
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| What is your fax
number? |
Fax |
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| What is your email
address? |
*Email |
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What is your date
of birth
(for discount purposes)? |
Date of Birth |
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| How would you rate
your credit? |
Credit |
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| Property
Information |
| What is the property address? |
Street |
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City |
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State |
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Zip |
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| What is your
mortgage balance? |
Mortagage Balance |
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| What is the market
value of your home? |
Market Value |
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| Number of
families? |
#Families |
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| What is the
dwelling type? |
Dwelling Type |
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| How many bedrooms
are there? |
Number of Bedrooms |
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| How many bathrooms
are there? |
Number of Full Bathrooms |
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Number of Half Bathrooms |
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| How many
fireplaces are there? |
Number of Fireplaces |
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| How many porches
or decks are there? |
Porches or Decks |
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Square Footage of
Porch/Deck |
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| What year was it
built? |
Year Built |
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| What date was the
property purchased? |
Purchase Date |
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| What is the
construction type? |
Construction Type |
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| How many
stories? |
Stories |
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| If two stories,
what is the ground floor square footage? |
Ground Floor Square
Footage |
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| What is the total
square footage of the building? |
Total Square Footage |
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| What is
the property's topography? |
Property's Topography |
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| What foundation
type? |
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| If structure is
located in a flood zone, what is the distance to
body of water? |
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| What type of
garage? |
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| What type roof
covering? |
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| Was the roof
updated? |
Updated Roof |
Yes No |
| If yes, what
year? |
Year Roof Updated |
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| Does the building
have a pool? |
Pool |
Yes No |
| If there is a
pool, is it fenced? |
Pool Fence |
Yes No |
| If there is a
pool, is there a lockable fence? |
Lockable Fence |
Yes
No |
| If there is a
pool, is there a diving board? |
Pool Diving Board |
Yes
No |
| If there is a
pool, is there a slide? |
Pool Slide |
Yes No |
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What is the distance of fire protection?
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| Is the building in
the brush? |
Brush |
Yes No |
| Is there a brush
hazard within one mile of the building? |
Brush Within 1 Mile |
Yes
No |
| If yes, has the
brush been cleared by 250 feet from all sides of
the building? |
Brush Cleared by 250
Feet |
Yes No |
| Is there a smoke
alarm? |
Smoke Alarm |
Yes No |
| Is there a fire
extinguisher? |
Fire Extinguisher |
Yes No |
| Are there
deadbolts? |
Deadbolts |
Yes No |
| Is the electrical
updated? |
Electrical Update |
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| Are there circuit
breakers? |
Circuit Breakers |
Yes
No |
| Does the
electrical circuit box have copper wiring? |
Copper Wiring |
Yes No |
| Do you have
central air? |
Central Air |
Yes No |
| How old is the
heating/ air conditioning? |
Age Heating/ Air
Conditioning |
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| Is the heating/
air conditioning thermostatically
controlled? |
Thermostatically
Controlled |
Yes No |
| What is the energy
source? |
Energy Source |
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| What is the heating system? |
Heating System |
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| What is the
cooling system? |
Cooling System |
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| Has the plumbing
been updated? |
Plumbing Updated |
Yes
No |
| Is the plumbing
copper? |
Copper |
Yes No |
| Does the building
have interior automatic fire sprinklers? |
Automatic Fire
Sprinklers |
Yes No |
| Is there a theft
alarm? |
Theft Alarm |
Yes No |
| Is there a fire
alarm? |
Fire Alarm |
Yes No |
| Are the alarms
Monitored? |
Monitored Alarms |
Yes
No
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| What is the
earthquake zone? |
Earthquake Zone |
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| Has it been
earthquake retrofitted? |
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| What is the fire
district? |
Fire District |
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| Do you have a
trampoline? |
Trampoline |
Yes No |
| Number of acres
dwelling is located on |
Number of acres |
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| Are there dogs on
the property? |
Dogs on Property |
Yes
No |
| If yes, how many
and what is the breed of each dog? |
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| Are there any
other pets or animals on the property? |
Pets or Animals |
Yes No |
| If yes,
how many and what is the description of each?
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| Current
Coverage Information |
| What is the
current insurance company? |
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| What is the
expiration date of current policy? |
Expiration Date |
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| 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? |
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| Desired
Coverage Information |
| Dwelling Amount
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Coverage A |
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| Other
Structures |
Coverage B |
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| Personal
Property |
Coverage C |
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| Loss of Use |
Coverage D |
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| Premise
Liability |
Coverage E |
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| Policy
Deductible |
Amount |
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| If earthquake
insurance is requested, select deductible
percentage % |
Earthquake Deductible |
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| Do you want building
replacement cost coverage? |
Yes No |
| Do you want contents
replacement cost coverage? |
Yes No |
| Questions or Comments |
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