Homeowners Quote Information
Settlement date
*
Homeowner's Information:
Name
*
Co-applicant name
Current mailing address
*
City
*
State
*
Zip
*
Home phone
*
Work phone
*
Cell phone
Date of birth
*
Marital status
*
Select
Single
Married
Co-applicant date of birth
Occupation
*
Co-applicant occupation
Property Location:
Address (if different from mailing above)
*
City
*
State
*
Zip
*
Exterior wall construction
*
Square footage
*
Number of stories
*
Year built
*
Townhouse
*
Select
No
Yes
E O G
*
Select
No
Yes
Distance to fire hydrant (ft)
*
Distance to fire station (miles)
*
Property Interior Description:
Number of full bathrooms
*
Number of half bathrooms
*
Central air conditioning
*
Select
No
Yes
Fireplace or chimney
*
Select
No
Yes
Finished basement
*
Select
No
Yes
Walkout basement
*
Select
No
Yes
Woodstove
*
Select
No
Yes
Deck
*
Select
No
Yes
Square footage of deck
*
Garage
*
Select
No
Yes
Garage attached or detached
*
Select
Attached
Detached
Porch
*
Select
No
Yes
Pool
*
Select
No
Yes
Pool Fence
*
Select
No
Yes
Miscellaneous:
Trampoline
*
Select
No
Yes
Pets
*
Breed
*
Jewelry to schedule
*
Select
No
Yes
Fine arts
*
Select
No
Yes
Residence employees
*
Select
No
Yes
Own another residence
*
Select
No
Yes
Business at home
*
Select
No
Yes
Filed for Bankruptcy in last 5 years
*
Select
No
Yes
Prior carrier
*
Cancel or non-renew
*
Select
No
Yes
Any losses (if YES, explain)
*
Select
No
Yes
Explain
*
Home Update Information:
(MUST BE COMPLETED FOR ALL HOME, REGARDLESS OF AGE):
Wiring
Year updated
*
Type of upgrade
*
Plumbing
Year updated
*
Type of upgrade
*
Heating
Year updated
*
Type of upgrade
*
Roof
Year updated
*
Type of upgrade
*
Credits:
Deadbolt
*
Select
No
Yes
Sprinklers
*
Select
No
Yes
Smoke detectors
*
Select
No
Yes
Fire extinguishers
*
Select
No
Yes
Central burglar alarm
*
Select
No
Yes
Central fire alarm
*
Select
No
Yes
Liability:
Liability limit (standard $300,000)
Deductible (standard $500)
Mortgagee Information:
Is property mortgaged?
*
Select
No
Yes
Mortgagee name
*
Address
*
City
*
State
*
Zip
*
Purchase price ($)
Loan Number
Mortgage amount ($)
Homeowner's Insurance Escrowed
Select
No
Yes
Bill Payor
Bill To
Select
Insured
Mortgagee
Current dwelling amount ($)
53 Loveton Circle, Suite 120 • Sparks, MD 21152
Phone • 1.800.926.8085 • 410.472.1620 • Fax • 410.472.1897
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