Personal Insurance
Auto
Motorcycle
RV's
Boat
Home
Condos
Renters
Manufactured Homes
Umbrella
Flood
Business Insurance
Business Insurance FAQ
Business Owners Policy (BOP)
Property & Liability
Restaurant Insurance
Special Liability
Worker's Compensation
Commercial Vehicle Ins
Misc. Commercial Insurance
Business Life & Disability
Life & Health
Life Insurance
Health Insurance
Dental
Disability
Long Term Care
Customer Service & Claims
Quotes & Service Req.
Claims Reporting Info.
Broker Change Info.
Be Prepared: Auto
Be Prepared: Property
Contact/About Us
Contact Us
About Us
Meet Our Staff
Companies We Represent
Home/Condo Owners Quote
No coverage is bound until you are contacted by one of our representatives
CONTACT INFORMATION
Name
Mailing Address
(if different)
City, State, Zip
Property Address
City, State, Zip
Preferred Phone
Select One
Cell
Home
Work
Other
Alternate Phone
Select One
Cell
Home
Work
Other
Email
Date of birth
Occupation
Employer
How long with current Employer
Referred by:
Select One
Google
Yellow Pages
Insurance Company
BloodyDecks.com
Ron Reitz - Quality Claims Management Corp.
Oscar Padilla MexicanInsurance.com
Other
If Insurance Company, please list name of Company
If Other please describe
SPOUSE INFORMATION
Date of birth
Occupation
Employer
Phone Number
Work
HOME TO BE INSURED
How long at present address
Previous home address if less
than 3 years at present address
IF MANUFACTURED HOME
a. Do you own or rent the land
Select One
Own
Rent
b. Is mobile home in a park?
Select One
Yes
No
If yes, park name
c. Mobile home Width & Length
d. Manufacturer Name
e. Model Name
f. Year Built
g. Serial Number
RATING INFORMATION
1. What year was this home built?
2. What type of construction was used?
Select One
Frame
Masonry
Aluminum Siding
3. Number of Stories
4. Occupancy
(check all that apply)
Owner occupied
Tenant occupied (long-term tenant)
Vacant
Vacation rental (short-term tenant)
Secondary/Vacation Home
Up for sale
Occupied by family/relative
5. Age of Roof
6. Roof Type
Select One
Tile
Asphalt (Composition)
Wood
Other
If Other
7. What style is your home?
Select One
Single Family Dwelling
Duplex (2 Families)
Tri-plex (3 Families)
Four-plex (4 Families)
Condominium
Manufactured Home
Other
10. How many full bathrooms in your home?
11. How many 3/4 bathrooms in your home?
12. How many 1/2 bathrooms in your home?
13. How many square feet on the first floor?
14. What type of home do you have?
Select One
Single story
Two story
Split level
Tri-Level
15. How many
total
living area square feet in your home? (Do not include square footage of garage etc)
16. Do you have a fireplace?
Select One
Yes
No
If yes, please describe what type
17. Do you have a woodstove?
Select One
Yes
No
If yes, please describe type and use
18. Do you have a garage?
Select One
Yes
No
If yes, please describe what type
Select One
Attached single car
Attached two car
Attached three car
Detached single car
Detached two car
Detached three car
Carport
19. What is your primary source of heat?
20. What is your secondary source of heat?
PROTECTIVE DEVICES:
21. Do you have a security system?
Select One
Yes
No
If yes, please describe what type
Burgler Alarm
Select One
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Select One
Yes
No
Smoke Detectors
Select One
Yes
No
22. Have you had any losses in the past 3 years?
Select One
Yes
No
If yes, please describe
23. Is this your first home?
Select One
Yes
No
If no, do you have current insurance?
Select One
Yes
No
24. Do you own any pets?
Select One
Yes
No
If yes, Please describe
25. Any Hot Tub, Sauna, Swimming Pool, Trampoline, wet Bar, Etc.?
Select One
Yes
No
If yes, Please describe
26. Any updates that have been done on home,
(i.e., new roof, electrical, heating, retrofitting, etc).
Select One
Yes
No
If yes, Please enter date complete and describe
IF THE BUILDING IS OVER 25 YEARS OLD, PLEASE ANSWER THE FOLLOWING:
27. Year Electricity was Updated
28. Is it on Circuit Breakers
Select One
Yes
No
29. Year Plumbiing was Updated
30. Copper or Galvanized Plumbing
Select One
Copper
Galvanized
Other
If Other please describe
CURRENT INSURANCE
1. Previous Carrier
2. Start date
End Date
3. How Long Insured
4. Policy Number
5. Prior Premium
$
6. Policy Renewal Date
COVERAGE INFORMATION
1. Dwelling
2. Contents
3. Liability
4. Medical Coverage
5. Deductibles
6. Loss of Use
Please use the space below to add comments regarding any special circumstances or coverage needs.
