Homeowners / Dwelling Fire

Name:
Street Address:
Town:
State:
ZIP:
Primary Insured's Social Security Number:
Primary Insured's Date of Birth:
Primary Insured's Occupation:
When do you need it?
Do you have insurance now?	--- Yes No
If Yes, when does it expire?
If No, please choose a reason:	--- Cancelled for Non-Pay Non-Renewed New Purchase
Type of Policy Needed:	Owner Occupied Dwelling / HO-3 Owner Occupied Condominium / HO-6 Renters Policy / HO-4 Tenant Occupied Dwelling / DP3 Tenant Occupied Condominium / DP3 Vacant Dwelling - No Renovations / DP1 Vacant Condo - No Renovations / DP1 Vacant Dwelling Under Renovation / DP1 Vacant Condo Under Renovation / DP1
COVERAGES:
Replacement Cost of Dwelling (If Applicable):
Replacement Cost of Improvements  (Condo Only)
Personal Property Limit:
Property Deductible:	$250 $500 $750 $1,000
Liability Limits Desired	$100,000 $300,000 $500,000 $1,000,000
UNDERWRITING INFORMATION:
Square Footage of Dwelling or Unit (Approx.):
Year Built:
Construction Type:	--- Wood Frame Brick
Is this new construction?	--- Yes No
Year Purchased:
Is this a new purchase?	--- Yes No
Distance of Closest Fire Hydrant:	--- 1,000 Feet or Less Over 1,000 Feet No Fire Hydrant
Distance of Closest Fire Station:	--- 5 Miles or Less Over 5 Miles
Foundation Type:	--- Full Basement Crawl Space Slab Piers or Pilings
-If Basement, what percentage is finished?	--- 0% - 10% 10%-25% 25%-50% 51% - 75% 76%-90% 91%-100%
Type of House: (Select All That Apply - Use Ctrl Key):	Rancher Split Level Two Story Three or More Story Condominium Unit Apartment Unit Duplex Triplex Quad or More
Number of Units:	--- 1 2 3 4 5 6 7 8 9 10+
Number of Bedrooms:	--- 1 2 3 4 5 6 7 8 9 10+
Number of Bathrooms:	--- 1 2 3 4 5+
Number of 1/2 Bathrooms:	--- 1 2 3 4 5+
Is this a modular home or prefab construction?	--- Yes No
Garage Type:	--- None Attached Detached
-Number of Cars:	---- 1 1.5 2 2.5 3 3.5 4 4.5 5+
Age of Roof:
Is Any Portion of Roof Flat	--- Yes No
Circuit Breaker or Fuses?	--- Circuit Breaker Fuses
Any Aluminum or Knob & Tube?	--- Yes No
Last Heating Update:		--- Partial Complete
Last Electric Update:		--- Partial Complete
Last Plumbing Update:		--- Partial Complete
Type of Heat:	--- Natural Gas Oil Electric Propane
If Oil Heat, Answer:	NA In Basement In Ground Above Ground On Slab Above Ground, No Slab
Any Fireplaces?	--- Yes No
-If So, How Many	--- 1 2 3 4 5+
Any Fireplace Inserts?	--- Yes No
Any Wood Stoves?	--- Yes No
-If So, Professionally Installed?	--- Yes No
Pool:	--- No Pool Above Ground and Fenced Above Ground, NOT Fenced In Ground and Fenced In Ground, NOT Fenced
If Pool, Answer:	--- No Diving Board or Slide Slide Only Diving Board Only Diving Board and Slide
Is your backyard fenced & locked?	--- Yes No
Do you own any pets?	--- Yes No	If Yes, Type & Breed ?
Do you have a trampoline?	--- No Yes
Any Custom Work or Materials: (Ex. Marble, Granite, Custom Millwork, Gourmet Kitchen)	--- No Yes
-If so, provide details:
Have You Had Any Claims in 5 Years?	--- Yes No
-If so, please list date and details regarding your     claim including type of claim and amount paid.
VACANT DWELLINGS ONLY:
Purchase Price of Property:
Expected Length of Vacancy	--- Under 3 Months 3-6 Months 6-12 Months Indefinate
Is Property Being Renovated?	--- Yes No
-If So, Please Describe Type of Renovations:
Amount of Renovations:
Comments or Special Instructions:
Contact's Phone Number (Include Area Code):
Contact's Fax Number (Include Area Code):
Contact's E-Mail Address: