|
Homeowners
Quote Form |
|
Please
provide the following information as accurate as possible.
Information provided will not be used for anything other than for the
purpose of this form. |
| Name: |
|
| Street
address for property: |
|
| City: |
|
| State: |
|
| Zip: |
|
| Phone: |
|
| E-Mail: |
|
| Date
of birth: |
|
County
in which the
home is located: |
|
| Year
built: |
|
| Time
in this home: |
|
| Type
of construction: |
|
| Structure
type: |
|
Number
of families
living in the home: |
|
| Number
of bedrooms: |
|
| Number
of bathrooms: |
|
What
is the total square
footage of your home under
heating and air conditioning?: |
|
What
size is the piece
of property on which the
structure is located?: |
|
How
many miles to the
nearest fire department
from the structure?: |
|
How
many feet to the
nearest fire hydrant?: |
|
Does
the home have
a trampoline?: |
|
Does
the home
have a pool?: |
|
Do
porches or decks have
attached railings?: |
|
Do
you have any
unattached structures
(sheds, outbuildings,
docks, or garages)?: |
|
| If
yes, what kind?: |
|
| If
yes, state dimensions: |
|
If
yes, state the values of
the structures (empty): |
|
| Fire
protection device: |
|
| Burglar
protection device: |
|
| Fire
sprinkling system?: |
|
Does
your home have a
covered porch, screened
enclosure, or lanai?: |
|
Value
of the home
(excluding the land): |
|
| Desired
deductible: |
|
| What
limits of personal liability?: |
|
Do
you want replacement
cost for your personal effects?: |
|
Will
there be an additional
insured on this property?: |
|
Do
you want coverage
for a golf cart?: |
|
Do
you have any special
items you want to insure
such as, jewelry, furs,
cameras, musical instruments,
silverware, golf equipment,
fine arts, or stamp collections?: |
|
If
yes, list items
and appraised values: |
|
How
many dogs
do you have?: |
|
Have
your dogs previously
bitten anyone?: |
|
What
breed of dogs
(either full breed
or mixed): |
|
Do
you have any
exotic pets, livestock,
or saddle animals?: |
|
If
so, what kind
and how many?: |
|
