HOMEOWNERS INSURANCE PROPOSAL REQUEST

 
Your Name:       
Address:          
City:                  State:   Zip Code: 
County:           
Home Phone:   Work:  Fax: 
E-Mail Address: 
Date of Birth:

The some of the following questions may require information contained on your current homeowners policy. If you do not have your current policy available for review leave the "answer" provided. You may leave comments or questions at the end of the questionnaire.
 

Residence Information

HO Form
Inside City Limits? Yes No
Is This a Primary or Secondary Residence? Year Built
Construction Type
Deductible Amount
Replacement Value of Residence:
 

Coverage Information

Personal Liability
Medical Payments
 

Replacement Cost Options

Replacement Cost on Dwelling
Replacement Cost on Contents

 

Protective Devices

Smoke Detectors
Dead Bolt Locks
Fire Extinguisher
Non Smoker
Central Station Burglar Alarm (rings at a monitoring center)
Central Station Fire Alarm (rings at a monitoring station)
Police Station Direct Alarm (rings at police station)
Fire Station Direct Alarm (rings at fire station)
Local Burlar Alarm (rings on the premises only)
Local Fire Alarm (rings on the premises only)
Automatic Sprinkler - All Areas
Automatic Sprinkler - Excluding Attic, Bath, Closet
 

Additional Coverages

Scheduled Property - Enter Total Dollar Amount of Itemized Coverage for each Category Earthquake Coverage? (Not Covered unless you select coverage)

Flood Coverage? (Not Covered unless you select coverage)


Please list all claims and amounts paid for the last 3 years:

Use this area for any special comments or coverages which need special attention.




Do you currently have homeowners insurance? Yes No
Who is you current homeowners insurance company?
When does your current policy expire?