HOME: (Select All that apply)
HOMEOWNERS INSURANCE QUOTE SHEET
(REVISED 04/2015)
Date:
Referred by:
GENERAL INFORMATION
Insured Name (1): Insured Name (2): Occupation: (1) Address: Prior Address: Email:
Current Coverage: o Y o N # Yrs:
(2)
Exp. Date:
DOB:
SSN:
DOB:
SSN:
Level of Education: (1)
(2)
Township/City:
County:
Zip:
Credit Check Permission: o Y o N
Phone:
Cell:
Current Rate:
Insurance Company:
UNDERWRITING
ANY CLAIMS OR LOSSES IN THE LAST 3 YEARS? o Y o N (IF YES, LIST DATES AND AMOUNTS PAID)
Do You...Own or Operate a business or a farm at your home: If so, describe:
Do You Have...(Select All that apply):
o SWIMMING POOL: (o IN-GROUND o ABOVE GROUND)
o HOT TUB
o POND/LAKE
o TRAMPOLINE
o PETS: IF DOG(S) BREED:
BITE HISTORY: o Y o N
o HORSES, MULES, PONIES EXOTIC ANIMALS:
o ALARM SYSTEM: o BURGLAR o CENTRAL o SPRINKLERS o OTHER
DEADBOLTS: ALL EXTERIOR DOORS o Y o N o FIRE EXTINGUISHERS
o SUPPLEMENTAL HEATING UNITS (CHECK ALL THAT APPLY) o WOOD STOVE o COAL STOVE o KEROSENE HEATER o MULTI-FUEL FURNACE o OTHER
Are you a : AAAmember: o Y o N if so, since when
AAA #
AARP member: o Y o N AARP #
HOME: (Select All that apply)
INSIDE CITY LIMITS: o Y o N
DISTANCE TO FIRE DEPT:
CONSTRUCTION TYPE: o FRAME o BRICK o OTHER
RESPONDING FIRE DEPT: YEARS AT ADDRESS:
DETACHED STRUCTURES:
YR BUILT:
PLUMBING UPDATED: o Y o N
YEAR
ELECTRIC UPDATED: o Y o N
YEAR
ROOF UPDATED:
oY oN
YEAR
HEATING UPDATED: o Y o N
YEAR
TYPE: o COPPER TYPE: o CIRCUIT BREAKERS TYPE: o ASPHALT SHINGLE TYPE: o NATURAL GAS
o PLASTIC o FUSES o SLATE o ELECTRIC
o GALVANIZED o ROMEX o METAL o FUEL OIL
o KNOB & TUBE o OTHER o LIQUID PROPANE
Do You Own: o GOLF CART o SNOWMOBILE o 2ND RESIDENCES/VACANT LAND
o 3/4 WHEELERS o FARM LAND
o CAMPER/RV
o BOAT/JET SKI
CURRENT COVERAGE ($)
o SCOOTER
o OTHER MOTORIZED VEHICLE
JEWELRY MOLD/FUNGUS: (LIABILITY BACKUP OF S & D DWELLING LOSS OF USE
CAMERA/VIDEO
ID THEFT
COLLECTIONS
ANTIQUES
PROPERTY
)
FINE ARTS
GUNS
0RDINANCE OR LAW
WIND/HAIL DEDUCTIBLE
POLICY DEDUCTIBLE
OTHER STRUCTURES
PERSONAL PROPERTY
PERSONAL LIABILITY
MEDICAL PAYMENTS
DO YOU WANT...
COVERAGE FOR: EARTHQUAKE: o Y o N
MOLD COVERAGE: o Y o N
FLOOD: o Y o N
PREMIUM BILLED TO INSURED OR MORTGAGEE: o BTI o MTGEE MORTGAGE HOLDER:
?COPYRIGHT 2015, KLEVE & ASSOCIATES IN SURANCE, BUR TON, OH ? 800 -466-9063 ? 4 40-834-4432
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