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Home/Mobile home Owner Quote
No coverage is bound until you are contacted by one of our representatives
Personal Information
Your Name
Street Address
Current Mailing Address
City
State
Zip
Email Address
Social Security #
Date of Birth
Occupation
Employer
How long with current employer?
Home Phone Number
-
-
Work Phone Number
-
-
Spouse Information
Spouse Name
Social Security #
Date of Birth
Occupation
Employer
Home Phone Number
-
-
Work Phone Number
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-
Home to be Insured
Street Address 1
Street Address 2
City
State
Zip
How long at present address
Previous home address if less
than 3 years at present address
If Mobile Home
Do you own or rent the land?
Own
Rent
Is this a mobile home park?
Yes
No
If Yes, park name
Mobile Home width & length
Manufacturer Name
Model Name
Year Built
Serial Number
Rating Information
What year was this home built?
What type of construction was used?
Frame
Masonry
Aluminumn Siding
Number of Stories
Other Occupancies
Age of roof
Roof Type
Composition
Metal
Other
If Roof Type Other
What style is your home?
Single Family
Apartment Building
Condominium
How will it be used?
Primary Residence
Secondary Residence
Seasonal
Farm
Unoccupied
Vacant
How many rooms in your home?
How many full bathrooms in your home?
How many 3/4 bathrooms in your home?
How many 1/2 bathrooms in your home?
How many square feet on the first floor?
What type of home do you have?
Single Story
Two Story
Split Level
Tri Level
Unoccupied
Vacant
How many total square feet in your home?
Do you have a fireplace?
Yes
No
If yes, please describe what type?
Do you have a wood stove?
Yes
No
If yes, describe what type and use
Do you have a garage?
Yes
No
If yes, please describe what type?
What is your primary source of heat?
What is your secondary source of heat?
Protective Devices
Do you have a security system?
Yes
No
If yes, describe what type
Do you have a burgler alarm
Yes
No
Describe what type of burgler alarm
Who is the alarm company?
Sprinkler system in building?
Yes
No
Smoke Detectors in building?
Yes
No
Have you had any losses in the last 3 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 Tub, Sauna, Swimming Pool, Trampoline, Wet Bar, etc.?
Yes
No
If yes, please describe?
Any updates that have been done on home?
Yes
No
If yes, please describe?
If the building is over 25 years old, please answer the following:
Year electricity was updated
Any updates that have been done on home?
Yes
No
Year plumbing was updated
Any updates that have been done on home?
Yes
No
Copper or galvanized plumbing?
Copper
Galvanized
Other
If other, please describe?
Current Insurance
Previous Carrier
Start Date
End Date
How long insured?
Amount insured for
Policy Number
Prior Premium
Policy Renewal Date
Coverage Information
Dwelling
Contents
Liability
Medical Coverage
Deductible - All Perils
Deductible - Wind/Hail/Storm
Loss of Use
Additional Insured
Name
Address
Phone Number
-
-
Fax Number
-
-
Account or Loan #
Lien Holder
Name
Address
Phone Number
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-
Fax Number
-
-
Loan Number
Mortgage Clause
Legal Description
Please use the space below to add comments regarding any special circumstances or coverage needs.