HOMEOWNERS QUOTE

PERSONAL INFORMATION

        First Name                                   
        Last Name                                    
        Phone Number                             
        Fax Number                              
        E-Mail Address

        Date of Birth

        Occupation

- Single Married/Domestic Partner Divorced Widowed               Marital Status                             
        Who Referred You to Our Site?  
 

PROPERTY INFORMATION

        Property Address                          
        Property City                                 
        Property Zip Code                         
- Single Family Duplex Triplex Fourplex Condo Townhouse                                   Dwelling Type                                

- Homeowners Renters Condominium                                   Type of Insurance requested (If renter's, skip down to Misc Info)
        Number of Bedrooms                   
        Number of Bathrooms                  
        Number of Fireplaces                   
- 1 Car Attached 2 Car Attached 3 Car Attached 1 Car Detached 2 Car Detached 3 Car Detached 1 Car Carport 2 Car Carport 3 Car Carport 1 Car Built-In 2 Car Built-In 3 Car Built-In                                Garage Description                       
        Year Built                                        
        Date You Purchased Your Home
- 1 2 3                                                      How Many Stories                         
        Ground Floor Square Footage     
        Total Square Footage                   
- Wood Frame Steel Frame Masonry Log Adobe                                    Construction Type

- Slab Built on Pillars-Piers Raised                           Foundation Type

- Gas Electric Other                                             Energy Source                            
- None Partial Full                                               Interior Automatic Fire Sprinklers
- None Local Central                                              Theft Alarm                                      
- None Local Central                                              Fire Alarm                          
- Asphalt Shingle/Composition Clay/Slate Tile Concrete Tile Tar and Gravel Wood Shake/Shingle Rock Corrugated Steel             Roof Type                                        
yes   no                                      Roof Updated;            Year:                                        
yes   no                                      Does the Dwelling Have a Pool   
yes   no                                      If Pool, Is it Fenced                       
yes   no                                      If Pool, Is There a Diving Board  
yes   no                                      If Pool, Is There a Slide                                     
yes   no                                      Is Dwelling in the Brush              
yes   no                                      Smoke Alarm                                  
yes   no                                      Fire Extinguisher                           
yes   no                                      Deadbolts                                        
yes   no                                      Electrical Updated;    Year:                           
yes   no                                      Circuit Breakers                             
yes   no                                      Copper Wiring

yes   no                                      Central Heating, Air Conditioning?
yes   no                                      Heating/Air Conditioning, Thermostatically Controlled

yes   no                                      Plumbing Updated;    Year:                            
yes   no                                      Copper Plumbing

REPLACEMENT COST INFORMATION

EXTERIOR WALLS

%    Brick on Frame

%    Brick, Solid

%    Concrete Block

%    Shakes, Wood

%    Siding

%    Stone on Frame

%    Stone, Solid

%    Stucco on Frame

DETACHED STRUCTURES

#     Basketball Court

#     Cabana

#     Gazebo

#     Hot Tub/Jacuzzi

#     Shed

#     Stable

#     Swimming Pool

#     Tennis Court

EXTERIOR FEATURES

#     Atrium Door

#     Specialty Window (Picture, Bay, Bow, Stained Glass, etc.)

#     Skylight

#     Solar Panel

#     Shutters

INTERIOR WALL FINISH

%    Wallpaper

%    Millwork

%    Mirror

%    Paint

%    Paneling

%    Tile

CEILING FINISH

%    Carpet

%    Drywall

%    Marble

%    Metal

%    Mirror

%    Plaster

%    Recessed Lighting

%    Stucco

%    Tile

%    Tongue and Groove

%    Wood

FLOOR FINISH

%    Carpet

%    Granite

%    Hardwood

%    Slate

%    Stone

%    Tile (ceramic, marble, mural, terrazzo)

%    Vinyl

OTHER INTERIOR ITEMS

#     French Door

#     Hot Tub

#     Jacuzzi

#     Spiral Staircase

#     Wet Bar

#     Elevator

#     Lift (chair or wheelchair)

MISCELLANEOUS INFORMATION

                                        
         Current Insurance Company        
         Exp. Date of Current Policy 

         Current Premium          
yes   no                                      Any Dogs on the Property

            
If Yes, Number & the Breed of Each Dog:
 

- None 1 2 3 4 5                                                 Losses or Claims in the last 5 years

 
If Yes, Date, Amount Paid & Description of Each Loss or Claim
 


COVERAGE INFORMATION

            Dwelling Amount (Coverage A)  
            Other Structures (Coverage B)   
            Personal Property (Coverage C) 
            Loss of Use (Coverage D)            
- 300,000 500,000 1,000,000                                             Premise Liability (Coverage E)    
- 500 1000 2500 5000 10,000                                                 Policy Deductible                            
- No Earthquake Coverage 10% Deductible 15% Deductible 20% Deductible                    Earthquake deductible, if selected  

- Yes No                                                    Scheduled Personal Property            Value: 

Questions or Comments to help the Agent:

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Thank you for your interest.