| Your
Home Information |
| Home
type |
|
| Residence
Type |
|
| Dwelling Replacement Cost |
|
| Year
Built |
|
| Construction
Type |
|
| Roof
Type |
|
| Number
of Stories |
|
| Square
Feet of House |
|
| Number
of Bedrooms |
|
| Number
of Bathrooms |
|
| Fireplace |
|
| Garage
Type |
|
| Central
Air Conditioning |
Yes
No |
| Basement |
Yes
No |
| Front
Porch |
Yes
No |
| Skylights |
|
| Interior
Plantation Window Shutters |
|
| Electrical
System |
|
| Utilities
Type |
|
| Home
Options |
Pool |
Gated
commu |
|
Yes
No |
Yes
No |
| Security
Options |
Smoke
Detectors |
Dead
Bolt Locks |
|
Yes
No |
Yes
No |
| Fire
Extinguisher |
Automatic
Fire Sprinklers |
|
Yes
No |
Yes
No |
|
Alarm System |
|
| Home
Owners Association? |
Yes
No |
| Your
Policy Information |
| When
do you need insurance by? |
(mm/dd/yy) |
| How
long have you lived at your present address? |
|
| If
you have coverage now, who is the Insurance
Company? |
|
|
Current Insurance Premium? |
|
| Is
your policy being Canceled or Non-Renewed?
(We can help!) |
Yes
No |
| If
you are being canceled or have any reported
claims in the last Five years, please briefly
explain why(reason/date/description/amount
paid /claim opened or closed)? |
|
| Desired
Deductible? |
|
| Liability
Amount? |
|
|
Medical Payments? |
|
| Do
you need jewelry coverage? |
Yes
No |
| Do
you need mortgage protection insurance?
|
Yes
No |
|
To receive a larger discount would you consider
also insuring your cars? |
Yes
No |
| Do
you need a Home Warranty Quote? |
Yes
No |
| Do
you need a Flood Insurance Quote? |
Yes
No |
|
Do you need an Umbrella Policy ? |
|
| Contact
Name |
|
| Property
Address |
|
| Property
City |
|
| Property
State |
|
| Zip
Code |
|
| Primary
Phone # to Reach You |
|
| Alternate
Phone # to Reach You |
|
| Fax |
|
| Email |
|
| Smoker |
Yes
No |
| Current
Age |
|
| Contact
Me During? |
|
| Currently
with Farmers? |
No
Yes |
If Yes, Policy Number(If
Available)
|
|
| |
|
