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 |
| 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 |
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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