HOMEOWNERS QUOTE FORM

Date:

Referred by:

Name:

Address:

City:          State:      Zip:

Phone:     Home            Work

E-mail address:

Property location:

Distance to fire hydrant: Less than 1000 feet    Over 1000 feet

Distance to full time fire station: Less than 5 miles    Over 5 miles

Current carrier:    Expiration date:

Any prior losses? Yes    No

If yes, please comment:

Style: Ranch    Cape    Split level        # of stories:    # of families:

Dimension of home:        Construction type: Frame    Masonry

Year built:    Basement:Yes    No    Finished:Yes    No 

Number of baths: Full     Half     

Decks or additions:Yes    No    Dimensions:

Woodstoves:Yes    No    Inspected:Yes    No

Fireplace:Yes    No     Hearth:Yes    No 

Attic:Yes    No    Finished:Yes    No    

Garage:Yes    No    Attached:Yes    No     Dimensions:   Stories:

Swimming pool:Yes    No    In ground    above ground    Fenced:Yes    No

Year of update: Roof:    Electric:    AMP:    Plumbing:

                            Burner:

Any smokers in the household?Yes    No    Smoke detectors:Yes    No    Deadbolts:Yes    No

Any business conducted at the home?Yes    No

Type:

Do you own a watercraft?Yes    No         

Extension of liability to other property:Yes    No     Camp    Second residents    Rental property

Do you own any dogs? Yes    No         Age:    Breed:

Would you like water back up coverage?:Yes    No 

Would you like coverage for food spoilage?:Yes    No 

Scheduled property:   

Jewelry   Value:     Furs    Value:       Silver     Value:   Other      Value:  

Desired or current coverage limits

Dwelling:   Other structures:    Personal property:    Loss of use:

Replacement cost contents:Yes    No             Replacement cost dwelling: Yes    No 

Liability Limit:        Deductible:

Please use this space below for any additional information that you would like us to have..