Homeowner Quote Form |
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| Send quote to you via: |
Telephone
Email
Fax
Regular Mail |
| First Name |
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| Middle Initial |
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| Last Name |
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| Current Address |
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| Address (cont.) |
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| City | |
| State/Province |
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| Zip/Postal code |
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| Property Address |
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| Address (cont.) |
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| City | |
| State |
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| Zip/Postal code |
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| Work Phone |
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| Home Phone |
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| FAX |
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| E-mail |
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| URL |
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| Purchase or Closing Date |
-- mm/dd/yy: |
| Purchase Price |
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| Amount of Mortgage |
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Year Built |
-yyyy |
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Number of Families |
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Construction Type
(choose one) |
Wood Frame
Joisted
Masonry (Brick)
Masonry
Non-combustible
Other
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| Will occupants of home be non-smokers? |
Yes
No
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Fire or Burglar alarm type |
Smoke
Detectors
Local Burglar and/or
Fire
Central Station Fire and Burglar
Central
Station Fire only
Central
Station Burglar only
Other
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Any claims in the past 5 years? (explain,
including
dates and amounts paid) |
Yes
No |
| Any Pets?(If yes, what type. If dog, what breed?) |
Yes
No |
| Age of Homeowners |
Owner 1:
Owner 2: |
| Any business conducted on premises? (If yes,
explain) |
Yes, explain
No |
Type of Electrical System
(check all that apply) |
Circuit Breakers
Fuses
<100 amp service
>=100 amp service
>=200 amp
service
Other
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| Year Electrical System last updated |
-yyyy |
Type of Plumbing System
(check all that apply) |
Copper Pipes
PVC Pipes
Lead Pipes
Other
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Year Plumbing last updated
(including water heater) |
-yyyy |
| Type of Heating System (check all that apply) |
Oil - Forced Hot Water
Oil - Forced
Hot Air
Gas - Forced
Hot Air
Gas - Forced
Hot Water
Other
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| Is there an oil or propane tank underground? |
Yes
No |
| Type of Roof (check all that apply) |
Asphalt Shingles (most common)
Clay Tile
Slate
Other
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| Square Footage of Home |
Ground Floor
Square Feet or,
Total Living Area
sq. ft. |
| Number of Stories: |
stories |
| Will dwelling be sold within the next year? |
Yes
No |
| Any commercial exposure within 1000 Ft? |
Yes
No If yes, explain in remarks at end of form.
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Have you had insurance canceled or declined
in the past 3 years?
(if yes, explain) |
Yes
No |
| Will home be owner occupied? (if not, explain) |
Yes
No
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Any domestic employees?
(e.g. nanny, maid) |
Yes
No |
| Remarks |
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Please enter the number of the following units in
your home: | |
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Bedroom(s) |
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Full Bathroom(s) |
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Half Bathroom(s) |
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Attached Garage |
# of bays
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Garage built into house (eg. under house or 1st flr) |
# of bays
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Open Porch/Deck/Breezeway |
sq. ft.
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Enclosed Porch or Breezeway |
sq. ft.
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Fireplace (standard size) |
# of chimneys
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Finished or Partially
Finished Basement |
sq. ft. finished
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Unfinished Basement |
sq. ft.
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Central Air Conditioning |
Yes
No
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Central Air Conditioning |
Uses heating ducts
or its own ducts
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Aluminum or Vinyl Siding |
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Brick or Stone Veneer on outside of home |
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