* Red questions are required.
Contact Information
Name:
Street Address:
City:
State:
Zip Code:
Daytime Phone Number:
Evening Phone Number:
Fax:
Email Address:
Best Time To Contact:
Home Information
Type of Residence:  Home
 Apartment (Skip Dwelling Coverage Question)
 Condo
If residence is a Condo, is your building covered by your association?  Yes (If Yes, skip dwelling coverage question.)  No
How long have you lived at your current residence?
Dwelling Coverage: $
Contents Coverage: $
Liability Coverage:
Umbrella Coverage:
Year Built:
Number of Stories:
Construction Type:
Square Footage:
# of Bathrooms:
Full:
 		Half:
Do you have a basement?  Yes     No
If you have a basement, is it finished?  Yes     No
Do you have a pool?  Yes     No
If you have a pool, is it fenced?  Yes     No
Who is your home occupied by?
# of Families:
Type of Heating:
If the type of Heating is Oil:
Where is the tank located?
How old is it?
Square Footage of Balcony or Deck:
Air conditioning:
Fireplace/Chimney:
Underwriting Information
Miles from Fire Department:
Feet from Hydrant:
Are you interested in Flood Coverage?  Yes     No
If yes, are you located in a Flood Zone?  Yes     No
Do you have any Dogs?  Yes     No
If yes, what kind?
Do you have an Alarm or Protective Device?
Is the home a non-smoking environment?  Yes     No
Is any business conducted in your home?  Yes     No
Please enter when updates were performed for the following:
Electric:
Heating:
Plumbing:
Roof:
Other:
Have you had any Homeowner losses in the past 3 years?  Yes     No
If yes, please explain:
Do you have any Property you wish to Schedule?
Are you interested in a Personal Excess Liability Policy?  Yes     No
Current Homeowner Carrier:
Driver Information
How many Drivers in Household:
Vehicle Information
How many Vehicles in Household:
Current Coverage Information
Are you currently insured?  Yes     No
If no, give reason:
If yes:
Company Name:
Policy Number
Expiration Date
Have you had a policy cancelled for non-payment of premium in the last 3 years?  Yes     No
Liability Amount:
Property Damage:
Uninsured Motorist:
Personal Injury Protection:
Verbal Threshold?  Yes     No
Collision:
Comprehensive:
Underwriting Information
Ever file for Bankruptcy?  Yes     No
Do you own your home?  Yes     No
Please select other types of insurance you currently have:  Long-Term Care
 Life Insurance
 Homeowners
 Disability Insurance
 Annuities
 Health Insurance
Please provide any additional information or comments below:
   
Please note: Completion of this form is for quotation purposes only and does not create a contract of insurance of any kind.