| E-mail Address: * | |
| Name * | |
| Contact Phone | |
| Fax | |
| Mailing Address * | |
| City * | |
| State * | |
| Zip Code * | |
About The
Property:
Address of Property |
|
| Property City | |
| Property State | |
| Property Zip | |
| How Long Have You Been At This Address? | |
| Previous Home Address If Less Than 3 Years At Present Address | |
If Property Is A Mobile
Home:
Do You Own Or Rent The Land? | Own
Rent |
| Is Mobile Home In A Park? | Yes
No |
| If Yes, What Is The Park Name? | |
| Mobile Home Width & Length | |
| Manufacturer Name | |
| Model Name | |
| Year Built | |
| Serial Number | |
Rating
Information:
What Year Was The Home Built? |
|
| What Type Of Construction Was Used? | |
| Number of Stories | |
| Other Occupancies (Business Operations, etc.)? | |
| Age of Roof? | |
| Roof Types | |
| If Other, Explain | |
| What Style Is Your Home? | |
| How Will The Home Be Used? | |
| How Many Rooms In The Home? | |
| How Many Full Bathrooms In The Home? | |
| How Many 3/4 Bathrooms? | |
| How Many 1/2 Bathrooms? | |
| How Many Square Feet On The First Floor? | |
| What Type of Home Do You Have? | |
| How Many TOTAL Square Feet In The Home? | |
| Do You Have A Fireplance? | Yes
No |
| If Yes, Describe What Type | |
| Do You Have A Woodstove? | Yes
No |
| If Yes, Describe What Type And How Its Used | |
| Do You Have A Garage? | Yes
No |
| If Yes, Please Describe What Type | |
| What Is Your Primary Source of Heating? | |
| What Is Your Secondary Source Of Heating? | |
Protective
Devices:
Do You Have A Security System? | Yes
No |
| If Yes, Please Describe What Type | |
| Burglar Alarm | Yes
No |
| If Yes, What Alarm Company? | |
| Sprinkler System? | Yes
No |
| Smoke Detectors? | Yes
No |
| Have You Had Any Homeowners Claims In The Past Three Years? | Yes
No |
| If Yes, Please Describe | |
| Is This Your First Home? | Yes
No |
| If No, Do You Have Current Insurance? | Yes
No |
| Do You Own Any Pets? | Yes
No |
| If Yes, Please Describe | |
| Any Hot Tubs, Saunas, Swimming Pools, Trampolines, Wet Bars, Etc.? | Yes
No |
| If Yes, Please Describe | |
| Any Updates To Home (i.e. New Roof, Electrical, Heating, Retrofitting, Etc.)? | Yes
No |
| If Yes, Please Describe Update and Date Completed | |
If Bulding Is Over 25 Years
Old:
Year Electricity Was Updated |
|
| Is It On Circuit Breakers? | Yes
No |
| Year Plumbing Was Updated | |
| Copper or Galvanized Plumbing? | |
| If Other, Explain | |
| Year Roof Installed | |
| Type of Roof | |
Coverage
Information:
Dwelling Coverage Requested ($) |
|
| Contents Coverage Requested ($) | |
| Liability Coverage Requested ($) | |
| Medical Coverage Requested ($) | |
| Desired All Perils (Standard) Deductible ($) | |
| Desired Wind/Hail/Storm Deductible | |
| Desired Loss Of Use Coverage ($) | |
Lien Holder/Mortgage
Information:
Lien Holder/Mortgage Name |
|
| Lien Holder/Mortgage Address | |
| Phone Number | |
| Fax Number (If Known) | |
| Loan Number | |
| Is There A Mortgage Clause? | |
| Additional Comments/Questions | |
|
| |
| * Required | Form by myContactForm.com |
