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Homeowner's Insurance Application
Homeowner's Insurance Application
Applicant
Applicant's Name:
(First)
(Middle)
(Last)
Other Named Insured:
(First)
(Middle)
(Last)
Mailing Address:
(Street Address)
(City)
(State)
(Zip)
Property Address (if different mailing):
(Street Address)
(City)
(State)
(Zip)
Previous Address (if current is less than three years):
(Street Address)
(City)
(State)
(Zip)
Telephone Number: Home
Work
Cell
Fax
Liability Coverage Requested:
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Email Address:
Social Security #:
Date of Birth:
(mm)
(dd)
(yy)
Marital Status:
Married
Single
Separated
Divorced
Widowed
Applicant Occupation:
Name of Employer:
Address of Employer:
# of years in current occupation:
# of years with current employer:
Smoker
Non-Smoker
Co-Applicant
Name of Co-Applicant:
(First)
(Middle)
(Last)
Other Named Insured:
(First)
(Middle)
(Last)
Mailing Address:
(Street Address)
(City)
(State)
(Zip)
Property Address (if different mailing):
(Street Address)
(City)
(State)
(Zip)
Previous Address (if current is less than three years):
(Street Address)
(City)
(State)
(Zip)
Telephone Number: Home
Work
Cell
Fax
Liability Coverage Requested:
25,000/50,000
50,000/100,000
100,000/300,000
250,000/500,000
Email Address:
Social Security #:
Date of Birth:
(mm)
(dd)
(yy)
Marital Status:
Married
Single
Separated
Divorced
Widowed
Applicant Occupation:
Name of Employer:
Address of Employer:
# of years in current occupation:
# of years with current employer:
Occupancy:
Owner
Tenant
Unoccupied
Vacant
Primary Residence:
Yes
No
Occupied Daily:
Yes
No
Usage Type:
Primary
Secondary
Seasonal
Home:
Single Family
Multi Family -
Number of Units:
Dwelling Coverage: $
Rental Income: $
Structure:
Brick
Frame
Other:
Building Type:
Fire Escape
Fire Resistive
Year Built:
Square Footage:
Number of Rooms:
Roof Material:
Shingle
Tar
Other:
Fireplace:
No
Yes, Amount:
Chimneys, Amount:
Pre-Fabricated, Amount:
Hearths, Amount:
Wood stove insert Amount:
Burglar Alarm:
None
Local
Central
Smoke Detector Alarm:
None
Local
Central
Deadbolt
Fire Extinguisher
Number of Floors:
Basement:
Yes
No
/ if Yes:
Finished
Unfinished
# of square feet in basement:
Garage:
Yes
No
/ if Yes:
Attached
Unattached
Renovations
Roofing:
Partial
Complete, Year done:
Plumbing:
Partial
Complete, Year done:
Heating:
Partial
Complete, Year done:
Electrical:
Partial
Complete, Year done:
Type of heating:
Gas
Oil
If oil, oil storage tank location:
Indoors
Outdoors
If outdoors,
above ground
below ground
Circuit Breakers:
Yes
No
Fuses:
Yes
No
Distance to nearest fire hydrant:
feet
Distance to nearest fire station:
mile(s)
Is there a trampoline on premises:
Yes
No
Is there a pool on premises:
Yes
No
Pets on premises:
No
Yes, Type
Value of personal property: $
Value of Kitchen: $
Value of Bathroom(s): $
Purchase Date:
(mm)
(dd)
(yy)
Purchase Price: $
Deductible Requested:
$250
$500
$1000
Mortgagee Information
Name of Bank:
Bank Address:
(Street Address)
(City)
(State)
(Zip)
Loan #:
Current Insurance Information
Current Insurance Carrier:
Policy #:
Premium:
Do you need additional coverage for any of the following items valued at a minimum of $1000 per item
Fine Arts or Valuables
Jewelry
Collectible (Rare Books, Coins, Stamps etc.)
Do you own a vehicle?
Yes
No
Would you like an Auto Quote?
Yes
No
Year
Make:
Model:
VIN #:
