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HOMEOWNER'S QUOTE WORKSHEET

Please fill out the form: In order to give you the best quote, please try to answer all the questions. Type "N/A" on any question that doesn't apply to you.

Section 1: General Information
Name: (as appears on the Deed)
Home phone Number:
Work phone Number:
Mobile phone Number:
E-mail Address:
Current Address:
Proposed Insurance Address:
Will the location be owner occupied:		Yes No
Number of Families:
Section 2: Insured Information
Occupation:
Date of Birth: (mm/dd/yyyy)
Social Security Number:
Years at Current Occupation:
Name of Employer:
Address of Employer:
Employer Phone Number:
Section 3: Insured's Spouse Information
Occupation:
Date of Birth: (mm/dd/yyyy)
Social Security Number:
Years at Current Occupation:
Name of Employer:
Address of Employer:
Employer Phone Number:
Section 4: Home Information
Are there any commercial exposures within 300 feet of insured property?:		Yes No
Purchase Price:
Mortgage Amount:
Closing Date:
Any Bankruptcies or Foreclosures ever?:		Yes No
	If yes, Please explain when and why:
Any oil tank on promises?:		Yes No
If yes, is it located above or below ground?:(please type N/A if this question is not applicable to you)
Do you have a copy of a recent satisfactory oil tank test?:		Yes No
Do you have first party insurance coverage with your oil company?:		Yes No
When was it last serviced?: (please type N/A if this question is not applicable to you)
Or when was it properly discarded?: (please type N/A if this question is not applicable to you)
Is the location under any renovation at this time?:		Yes No
If yes, what type of renovation?: (please type N/A if this question is not applicable to you)
Roof Type:		Peaked Flat
Roof Material:
Age of Roof:
When was it last updated?: (please type N/A if this question is not applicable to you)
What kind of update?:		N/A Complete Update Partial Update
When plumbing was updated?: (please type N/A if this question is not applicable to you)
Any known leak?:		Yes No
When wiring was updated?:
Is electric service...?:		110V 220V
Does the property have circuit breakers?:		Yes No
Any active knob and tube wiring?:		Yes No
Is there a trampoline on the property?:		Yes No
Is there a fireplace?:		Yes No
Is there a wood burning stove?:		Yes No
How far is the nearest fire hydrant?:
How far is the nearest fire station?:
Did the insured have any losses in the last 3 years?:		Yes No
	If yes, Please explain how much and when:
Does the property have a swimming pool?:		Yes No
Is it completely fenced?:		Yes No
How deep is the pool?: (please type N/A if this question is not applicable to you)
Does the pool have a:		Diving Board A Slide N/A
Do you or any other tenant own or control any animals?:		Yes No
What kind of breed?: (please type N/A if this question is not applicable to you)
How old is the animal?: (please type N/A if this question is not applicable to you)
Does it have all the shots?:		Yes No N/A
Is there any biting history?:		Yes No N/A
How much does it weight?: (please type N/A if this question is not applicable to you)
Do you or your tenant run a business from home?:		Yes No
If yes, what business: (please type N/A if this question is not applicable to you)
Do you have your clients meets you at your home?:		Yes No
Number of bedrooms:
Number of bathrooms:
Number of car garages:
Is the car garage...?:		Attached Detached N/A
Square footage of the house:
Is basement finished?:		Yes No
Square footage of the basement:
Section 5: Closing Lawyer Information
Name:
Address:
Phone number:
Fax number:
Section 6: Mortgage Company Information
Name:
Phone number:
Fax number:
Mortgage Clause:
Address:
Section 7: Bank/Mortgage Representative Information
Name:
Phone number:
Fax number:
Section 8: Realtor Information
Name:
Phone number:
Fax number:
Additional Remarks & Comments