Personal Information |
| * Name: |
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| * Address: |
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| * City: |
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| * State; |
|
| * Zip: |
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| * Home Phone: |
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| Work Phone: |
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| Fax: |
|
| * Email: |
|
What is your date of birth?
(for discount purposes) |
mm/dd/yyyy |
How would you
rate your credit? |
|
| |
Property Information |
| * Property Street |
|
| * Property City |
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| * Property State |
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| * Property Zip |
|
* What is your
mortgage balance? |
|
* What is the
market value
of your home? |
|
| Number of families? |
|
| What is the dwelling
type? |
|
How many bedrooms
are there? |
|
How many full bathrooms
are there? |
|
How many half bathrooms
are there? |
|
How many fireplaces
are there? |
|
How many porches
or decks are there? |
|
| Square Footage of Porch/Deck |
|
| What year was
it built? |
|
| What date was
the property purchased? |
|
What is the
construction type? |
|
| How
many stories? |
|
| If two stories,
what is the ground floor square footage? |
|
| What is the
total square footage of the building? |
|
| What
is the property's topography? |
|
| What foundation
type? |
|
| If structure
is located in a flood zone, what is the distance to body of water? |
|
| What type of
garage? |
|
| What type roof
covering? |
|
| Was the roof
updated? |
Yes
No |
| If yes, what
year? |
|
Does the building
have a pool? |
Yes
No |
If there is
a pool,
is it fenced? |
Yes
No |
If there is
a pool,
is there a lockable fence? |
Yes
No |
If there is
a pool,
is there a diving board? |
Yes
No |
If there is
a pool,
is there a slide? |
Yes
No |
What is the distance of fire protection? |
|
| Is the building
in the brush? |
Yes
No |
| Is there a brush
hazard within one mile of the building? |
Yes
No |
| If yes, has
the brush been cleared by 250 feet from all sides of the building? |
Yes
No |
| Is there a smoke
alarm? |
Yes
No |
| Is there a fire
extinguisher? |
Yes
No |
| Are there deadbolts? |
Yes
No |
| Is the electrical
updated? |
|
| Are there circuit
breakers? |
Yes
No |
| Does the electrical
circuit box have copper wiring? |
Yes
No |
| Do you have
central air? |
Yes
No |
| How old is the
heating/air conditioning? |
|
| Is the heating/air conditioning thermostatically controlled? |
Yes
No |
| What is the
energy source? |
|
| What is the
heating system? |
|
| What is the
cooling system? |
|
Has the plumbing
been updated? |
Yes
No |
| Is the plumbing
copper? |
Yes
No |
| Does the building
have interior automatic fire sprinklers? |
Yes
No |
| Is there a theft
alarm? |
Yes
No |
| Is there a fire
alarm? |
Yes
No |
| Are the alarms
Monitored? |
Yes
No |
What is the
earthquake zone? |
|
Has it been
earthquake retrofitted? |
|
| What is the
fire district? |
|
| Do you have
a trampoline? |
Yes
No |
Number of acres
dwelling is located on |
|
Are there dogs
on the property? |
Yes
No |
| If yes, how
many and what is the breed of each dog? |
|
Are there any
other pets
or animals on the property? |
Yes
No |
| If
yes, how many and what is the description of each? |
|
| |
Current Coverage Information |
| What is the current insurance
company? |
|
| What is the expiration date of
current policy? |
|
| Where there any losses or claims
in the last 5 years? |
Yes
No |
| If yes, what is the date, amount
paid and description of each loss or claim? |
|
| |
Desired Coverage Information |
| Dwelling Amount |
|
| Other Structures |
|
| Personal Property |
|
| Loss of Use |
|
| Premise Liability |
|
| Policy Deductible |
|
| If earthquake insurance is requested,
select deductible percentage % |
|
| Do
you want building replacement cost coverage? |
Yes
No |
| Do you want contents replacement cost coverage? |
Yes
No |
| Questions or Comments |
|
|
Friendly Agents. Fast Quotes. Local Service
