| Personal Information |
| What is your name? |
Last* |
|
First* |
|
Middle |
|
| What is your telephone
number? |
Home* |
|
Work* |
|
| What is your email address? |
Email* |
|
| What is your mailing address? |
Street |
|
City |
|
State |
|
Zip |
|
| What is your fax number? |
Fax |
|
| What is your
date of birth (for discount purposes)? |
Date of Birth |
|
| How would you
rate your credit? |
Credit |
|
| Property Information |
| What
is the property address? |
Street |
|
City |
|
State |
|
Zip |
|
| What is your
mortgage balance? |
Mortagage Balance |
|
| What is the
market value of your home? |
Market Value |
|
| Number of families? |
#Families |
|
| What is the dwelling
type? |
Dwelling Type |
|
| How many bedrooms
are there? |
Number of Bedrooms |
|
| How many bathrooms
are there? |
Number of Full Bathrooms |
|
| |
Number of Half Bathrooms |
|
| How many fireplaces
are there? |
Number of Fireplaces |
|
| How many porches
or decks are there? |
Porches or Decks |
|
| |
Square Footage of Porch/Deck |
|
| What year was
it built? |
Year Built |
|
| What date was
the property purchased? |
Purchase Date |
|
| What is the
construction type? |
Construction Type |
|
| How
many stories? |
Stories |
|
| If two stories,
what is the ground floor square footage? |
Ground Floor Square Footage |
|
| What is the
total square footage of the building? |
Total Square Footage |
|
| What
is the property's topography? |
Property's Topography |
|
| What foundation
type? |
|
| If structure
is located in a flood zone, what is the distance to body of water? |
|
| What type of
garage? |
|
| What type roof
covering? |
|
| Was the roof
updated? |
Updated Roof |
Yes;
No |
| If yes, what
year? |
Year Roof Updated |
|
| Does the building
have a pool? |
Pool |
Yes;
No |
| If there is
a pool, is it fenced? |
Pool Fence |
Yes;
No |
| If there is
a pool, is there a lockable fence? |
Lockable Fence |
Yes;
No |
| If there is
a pool, is there a diving board? |
Pool Diving Board |
Yes;
No |
| If there is
a pool, is there a slide? |
Pool Slide |
Yes;
No |
What is the distance of fire protection?
|
| Is the building
in the brush? |
Brush |
Yes;
No |
| Is there a brush
hazard within one mile of the building? |
Brush Within 1 Mile |
Yes;
No |
| If yes, has
the brush been cleared by 250 feet from all sides of the building? |
Brush Cleared by 250 Feet |
Yes;
No |
| Is there a smoke
alarm? |
Smoke Alarm |
Yes;
No |
| Is there a fire
extinguisher? |
Fire Extinguisher |
Yes;
No |
| Are there deadbolts? |
Deadbolts |
Yes;
No |
| Is the electrical
updated? |
Electrical Update |
|
| Are there circuit
breakers? |
Circuit Breakers |
Yes;
No |
| Does the electrical
circuit box have copper wiring? |
Copper Wiring |
Yes;
No |
| Do you have
central air? |
Central Air |
Yes;
No |
| How old is the
heating/ air conditioning? |
Age Heating/ Air Conditioning |
|
| Is the heating/
air conditioning thermostatically controlled? |
Thermostatically Controlled |
Yes;
No |
| What is the
energy source? |
Energy Source |
|
| What is the
heating system? |
Heating System |
|
| What is the
cooling system? |
Cooling System |
|
| Has the plumbing
been updated? |
Plumbing Updated |
Yes;
No |
| Is the plumbing
copper? |
Copper |
Yes;
No |
| Does the building
have interior automatic fire sprinklers? |
Automatic Fire Sprinklers |
Yes;
No |
| Is there a theft
alarm? |
Theft Alarm |
Yes;
No |
| Is there a fire
alarm? |
Fire Alarm |
Yes;
No |
| Are the alarms
Monitored? |
Monitored Alarms |
Yes;
No |
| What is the
earthquake zone? |
Earthquake Zone |
|
| Has it been
earthquake retrofitted? |
|
| What is the
fire district? |
Fire District |
|
| Do you have
a trampoline? |
Trampoline |
Yes;
No |
| Number of acres
dwelling is located on |
Number of acres |
|
| Are there dogs
on the property? |
Dogs on Property |
Yes;
No |
| If yes, how
many and what is the breed of each dog? |
|
| Are there any
other pets or animals on the property? |
Pets or Animals |
Yes;
No |
| If
yes, how many and what is the description of each? |
|
| Current Coverage Information |
| What is the current insurance
company? |
|
| What is the expiration date of
current policy? |
Expiration Date |
|
| Where there any losses or claims
in the last 5 years? |
Losses - Claims |
Yes;
No |
| If yes, what is the date, amount
paid and description of each loss or claim? |
|
| Desired Coverage Information |
| Dwelling Amount |
Coverage A |
|
| Other Structures |
Coverage B |
|
| Personal Property |
Coverage C |
|
| Loss of Use |
Coverage D |
|
| Premise Liability |
Coverage E |
|
| Policy Deductible |
Amount |
|
| If earthquake insurance is requested,
select deductible percentage % |
Earthquake Deductible |
|
| Do
you want building replacement cost coverage? |
Yes;
No |
| Do
you want contents replacement cost coverage? |
Yes;
No |
| Questions or Comments |
|
If you have more than 1 residence,
please fill out another form
Please Note: Insurance coverage cannot be bound without a written
binder from our office.
Please Also Note: Many insurance carriers use information gathered
from you and outside sources about your claim, credit history
and home. This information allows insurance companies to determine
accurately the proper price to charge. You are entitled to a
free copy of the reports by contacting the appropriate consumer
reporting agency within the next 60 days.
By filling out this form, you agree to the above terms.
|
