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Homeowner Insurance Quote

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Contact Information

Name:
Email address:
Home phone:
Business phone:
Address:

City:
County:
State:
Zip code:

Location of Property
(If different from above)

Address:

City:
County:
State:
Zip code:

Property Details

Year built:

Occupied by:

Owner

Tenant(s)

Number of families:

Building materials:
(Check all that apply)

	Frame		Log
	Masonry

Fire Safety:

Distance to Hydrant:

(feet)

Distance to Fire Department:

(miles)

Fire Extinguiser(s):

Smoke Detectors:

Do any residents smoke?:

Do you have an underground fuel tank?:

Heating System:

Primary heating type:

Secondary heating type:

General Safety:

Wiring type:

Temperature control:

Burglar alarm:

Swimming pool:

None

Above ground

In-ground

Approved fence

Diving board

Latest Renovations:

Wiring renovated:

(year)

Plumbing renovated:

(year)

Heating renovated:

(year)

Roofing renovated:

(year)

Exterior painted:

(year)

Coverage Limits

Dwelling Coverage:

Coverage Limit

Additional Structures:

Yes

10% of dwelling value is automatically given, if additional coverage is needed, please list the desired amout:

Additional Coverage:

Personal Property

Loss of Use

General Information

Any flooding, brush, forest fire hazard, landslide hazard, et cetera on the property?

Is there a trampoline on the premises?

Are there animals living on the premises?

Animals:

Yes

Number:

Type:

Breed:

Age:

Comments:

Any Recreational Vehicles?

Recreational Vehicle:

Yes

Description:

Loss History
Any losses whether or not paid by insurance, during the last three years, at this or any other location.

Date	Type	Description of loss	Amount

Prior Coverage

Prior Carrier	Policy Number

Has your coverage lapsed within the last 12 months?

Additional Comments