ABOUT YOU

Name:

Address:

City | State | Zip:

Telephone:

HOME       BUSINESS      CELL

E-Mail Address

Telephone

E-Mail

US Mail

 YOUR CURRENT INSURER

Your Present Insurer:

Your Expiration Date:

Construction Type:

Frame Masonry Select from list. Other

Year Built:

Fire District:

Distance to Fire Station:

Less than 5 miles. More than 5 miles. Select from list.

Distance to Hydrant:

Less than 1,000 feet. More than 1,000 feet. Select from list.

Do you have a smoke detector?

Yes

No

Do you have a fire extinguisher?

Yes

No

Do you have a Central Station Alarm?

Yes

No

Do you need Flood Insurance?

Yes

No

 AMOUNT OF INSURANCE REQUESTED

Dwelling:

$

Contents:

$

(for Renter’s quote only)

Liability:

$

300K 500K 1 MM Select from list.

Deductible:

$

$100 $250 $500 $1,000 $1,500 $2,000 $2,500 and above Select from list.

 ABOUT YOUR PROPERTY

Kitchen

1 2 3 +

Den/Study

1 2 3 + No

Laundry

1 2 3 + No

Wood stove

1 2 3 4 5 + No

Living Room

1 2 3 +

Family Room

1 2 3 + No

Deck (sq. ft.)

Fireplace

1 2 3 4 5 + No

Dining Room

1 2 3 + No

Full Bath

1 2 3 4 5 + No

Open Porch

1 2 3 4 5 + No

Other

Bedroom

1 2 3 4 5 +

Half Bath

1 2 3 4 5 + No

Enclosed Porch

1 2 3 4 5 + No

Living Space
 (sq. ft.)

This property serves as a

  Primary Residence

  Secondary Residence

  Seasonal Rental

How many family units in structure?

1 Family 2 Family 3 Family 4 Family 5 Family 6 + Family

Do you have a dog?

  Yes    No

What breed?

Do you have horses?

  Yes    No

How many?

none 1 2 3 or more

Do you have a pool?

no Fenced - in ground Above ground 3 or more

Do you engage in farming activity including rental of land?

  Yes    No

Any business activity on premises?

  Yes    No

Any losses/claims in the last 5 years?

if Yes, please describe loss and $ amount paid to you for the claim.

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