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Your
Full Name:
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Email
address:
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Date
of Birth:
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Spouse
Full Name:
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Date
of Birth:
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Street
Address:
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City:
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State:
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Zip:
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County:
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Phone
number where we can
contact you:
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Best
time to reach you?
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Do
you own your home, or do you rent?
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Is
this a condominium or townhouse unit?
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Year
of construction of home:
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Total
square feet:
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Style
of home:
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Type
of garage:
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Is
the garage attached or detached from your home?
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Is there built-in living space above the garage?
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Is
this a normal tract home, or is it custom built?
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How
many full baths?
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How
many half baths?
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How
many fireplaces?
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Roof
type (I.e. wood shake, etc.):
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Exterior
of home (I.e. stucco, etc.):
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Is
there a burglar alarm?
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Is
there a separate jacuzzi / hot tub?
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Wet
bar?
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Are
there fire sprinklers in the attic?
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Is
this a new home purchase?
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If
yes, escrow close date:
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Name
of current insurance carrier:
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Renewal
date:
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Number
of losses in the past three years:
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Amount
paid if known:
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Non-smoker?
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Are
you over the age of 50?
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Any
special riders, increased coverage limits on certain items, i.e.
jewelry, fine arts etc.
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Are
you interested in earthquake, flood and various options available?
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Do
you have an Umbrella liability policy?
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Auto
carrier?
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